A Historical Note on the Development of Zimelidine, the First Selective Serotonin Reuptake Inhibitor

In 1960s, evidence began to emerge suggesting a significant role of serotonin in depression. This led to the development of zimelidine, the first selective serotonin reuptake inhibitor (SSRI). Zimelidine was derived from pheniramine and was marketed in Europe in 1982. However, it was removed from the market in 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome.

Despite its short-lived availability, zimelidine paved the way for the development of other SSRIs such as fluoxetine, which was approved by the FDA in 1987 and launched in the US market in 1988 under the trade name Prozac. The development of SSRIs revolutionized the treatment of depression and other mood disorders, providing a safer and more effective alternative to earlier antidepressants such as the tricyclics and MAO inhibitors.

Antidepressants can cause sexual dysfunction as a side-effect, although the rates vary. The impact on sexual desire, arousal, and orgasm can differ depending on the type of antidepressant. It is important to rule out other causes and consider non-pharmacological strategies such as reducing the dosage of taking drug holidays. If necessary, switching to a lower risk antidepressant of using pharmacological options such as phosphodiesterase inhibitors of mirtazapine augmentation can be considered. The Maudsley Guidelines 14th Edition provides a helpful table outlining the risk of sexual dysfunction for different antidepressants.

Torsades de pointes may not be present on an ECG even if the patient experiences recurring episodes, as it has a tendency to appear and disappear.

QTc Prolongation: Risks and Identification

The QT interval is a measure of the time it takes for the ventricles to repolarize and is calculated from the beginning of the QRS complex to the end of the T wave. However, the QT interval varies with the heart rate, making it difficult to use a single number as a cut-off for a prolonged QT. Instead, a corrected QT interval (QTc) is calculated for each heart rate using various formulas. A QTc over the 99th percentile is considered abnormally prolonged, with approximate values of 470 ms for males and 480 ms for females.

Prolonged QT intervals can lead to torsade de pointes (TdP), a polymorphic ventricular tachycardia that can be fatal if it degenerates into ventricular fibrillation. TdP is characterized by a twisting of the QRS complexes around an isoelectric line and is often asymptomatic but can also be associated with syncope and death. An accurate diagnosis requires an ECG to be recorded during the event. It is important to note that an increase in the QT interval due to a new conduction block should not be considered indicative of acquired LQTS and risk for TdP.

Allosteric modulators are substances that bind to a receptor and alter the way the receptor responds to stimuli.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Flumazenil acts as an antagonist for GABA-A receptors and is known to reverse the effects of benzodiazepines. While there is some speculation that it may also have an effect on alcohol, this has not been definitively proven.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Chlorpromazine: Photosensitivity Reactions and Patient Precautions

Chlorpromazine, the first drug used for psychosis, is a common topic in exams. However, it is important to note that photosensitivity reactions are a known side effect of its use. Patients taking chlorpromazine should be informed of this and advised to take necessary precautions. Proper education and awareness can help prevent potential harm from photosensitivity reactions.

The preferred initial treatment for alcohol withdrawal syndrome is benzodiazepines.

Medication Types:

Atomoxetine (Strattera) is a medication used to treat ADHD by inhibiting the reuptake of noradrenaline. It has a similar structure to some antidepressants.

Acamprosate is a medication that acts as an antagonist at NMDA receptors and is the only medication licensed for the relief of cravings in alcohol dependence.

Alprazolam is a benzodiazepine medication.

Amisulpride is an atypical (second generation) antipsychotic medication that works as a serotonin and dopamine antagonist.

Aripiprazole is an atypical antipsychotic medication that acts as a partial agonist at dopamine receptors.

The Maudsley Guidelines 10th Edition state that there are several independent risk factors for QT prolongation, including being female, having hypokalemia, hypomagnesemia, hypocalcemia, and having anorexia nervosa.

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

Understanding Bioavailability in Drug Trials

Bioavailability is a crucial factor in drug trials, as it determines the percentage of a drug that reaches the systemic circulation after administration. This can be affected by factors such as absorption and metabolic clearance. For example, if a drug called X is administered orally and only 60% reaches the systemic circulation, its bioavailability is 0.6 of 60%. However, if the same drug is administered intravenously, plasma levels may reach 100%.

One way to potentially increase bioavailability is through the rectal route, which bypasses around two thirds of the first-pass metabolism. This is because the rectum’s venous drainage is two thirds systemic (middle and inferior rectal vein) and one third portal (superior rectal vein). As a result, drugs administered rectally may reach the circulatory system with less alteration and in greater concentrations. Understanding bioavailability and exploring different administration routes can help optimize drug efficacy in clinical trials.

A lack of vitamin C is commonly linked to gum inflammation and bleeding.

Thiamine Deficiency and Alcohol-Related Brain Disease

Thiamine deficiency is a well-known cause of a neurological disorder called Wernicke-Korsakoff syndrome (WKS) in individuals with alcohol use disorder. Thiamine, also known as vitamin B1, is an essential nutrient that cannot be produced by the body and must be obtained through the diet. Thiamine is required for the proper functioning of enzymes involved in the metabolism of carbohydrates, the synthesis of neurotransmitters, nucleic acids, fatty acids, and complex sugar molecules, and the body’s defense against oxidative stress.

Three enzymes that require thiamine as a cofactor are transketolase, pyruvate dehydrogenase (PDH), and alpha ketoglutarate dehydrogenase (KGDH), all of which participate in the breakdown of carbohydrates. Thiamine deficiency leads to suboptimal levels of functional enzymes in the cell, which can cause cell damage in the central nervous system through cell necrosis, cellular apoptosis, and oxidative stress.

Alcoholism can contribute to thiamine deficiency through inadequate nutritional intake, decreased absorption of thiamine from the gastrointestinal tract, and impaired utilization of thiamine in the cells. Giving thiamine to patients with WKS can reverse many of the acute symptoms of the disease, highlighting the importance of this nutrient in the prevention and treatment of alcohol-related brain disease.

The half-life of a drug is the time taken for its concentration to fall to one half of its value. Drugs with long half-lives may require a loading dose to achieve therapeutic plasma concentrations rapidly. It takes about 4.5 half-lives to reach steady state plasma levels. Most drugs follow first order kinetics, where a constant fraction of the drug in the body is eliminated per unit time. However, some drugs may follow zero order kinetics, where the plasma concentration of the drug decreases at a constant rate, despite the concentration of the drug. For drugs with nonlinear kinetics of dose-dependent kinetics, the relationship between the AUC of CSS and dose is not linear, and the kinetic parameters may vary depending on the administered dose.

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

Oxazepam is a significant metabolite found in various benzodiazepines, but it does not produce any significant metabolites of its own. It is occasionally prescribed to individuals with liver impairment because it does not necessitate hepatic oxidation and is instead metabolized through glucuronidation (which is often preserved even in severe liver disease).

The Significance of Active Metabolites in Drug Discovery and Development

Certain drugs are classified as prodrugs, which means that they are inactive when administered and require metabolism to become active. These drugs are converted into an active form, which is referred to as an active metabolite. Some drugs have important active metabolites, such as diazepam, dothiepin, fluoxetine, imipramine, risperidone, amitriptyline, and codeine, which are desmethyldiazepam, dothiepin sulfoxide, norfluoxetine, desipramine, 9-hydroxyrisperidone, nortriptyline, and morphine, respectively.

The role of pharmacologically active metabolites in drug discovery and development is significant. Understanding the active metabolites of a drug can help in the development of more effective and safer drugs. Active metabolites can also provide insights into the pharmacokinetics and pharmacodynamics of a drug, which can aid in the optimization of dosing regimens. Additionally, active metabolites can have different pharmacological properties than the parent drug, which can lead to the discovery of new therapeutic uses for a drug. Therefore, the study of active metabolites is an important aspect of drug discovery and development.

Pharmacological management of dementia involves the use of acetylcholinesterase inhibitors (AChE inhibitors) and memantine. AChE inhibitors prevent the breakdown of acetylcholine, which is deficient in Alzheimer’s due to the loss of cholinergic neurons. Donepezil, galantamine, and rivastigmine are commonly used AChE inhibitors in the management of Alzheimer’s. However, gastrointestinal side effects such as nausea and vomiting are common with these drugs.

Memantine, on the other hand, is an NMDA receptor antagonist that blocks the effects of pathologically elevated levels of glutamate that may lead to neuronal dysfunction. It has a half-life of 60-100 hours and is primarily renally eliminated. Common adverse effects of memantine include somnolence, dizziness, hypertension, dyspnea, constipation, headache, and elevated liver function tests.

Overall, pharmacological management of dementia aims to improve cognitive function and slow down the progression of the disease. However, it is important to note that these drugs do not cure dementia and may only provide temporary relief of symptoms.

Antipsychotic drugs are known to cause weight gain, but some more than others. The reason for this is not due to a direct metabolic effect, but rather an increase in appetite and a decrease in activity levels. The risk of weight gain appears to be linked to clinical response. There are several suggested mechanisms for this, including antagonism of certain receptors and hormones that stimulate appetite. The risk of weight gain varies among different antipsychotics, with clozapine and olanzapine having the highest risk. Management strategies for antipsychotic-induced weight gain include calorie restriction, low glycemic index diet, exercise, and switching to an alternative antipsychotic. Aripiprazole, ziprasidone, and lurasidone are recommended as alternative options. Other options include aripiprazole augmentation, metformin, orlistat, liraglutide, and topiramate.

Mechanisms of action for illicit drugs can be classified based on their effects on ionotropic receptors of ion channels, G coupled receptors, of monoamine transporters. Cocaine and amphetamine both increase dopamine levels in the synaptic cleft, but through different mechanisms. Cocaine directly blocks the dopamine transporter, while amphetamine binds to the transporter and increases dopamine efflux through various mechanisms, including inhibition of vesicular monoamine transporter 2 and monoamine oxidase, and stimulation of the intracellular receptor TAAR1. These mechanisms result in increased dopamine levels in the synaptic cleft and reuptake inhibition.

Antipsychotics and Their Effects on EEG

The use of antipsychotics has been found to have an impact on the EEG of patients taking them. A study conducted on the subject found that clozapine had the highest percentage of EEG changes at 47.1%, followed by olanzapine at 38.5%, risperidone at 28.0%, and typical antipsychotics at 14.5%. Interestingly, quetiapine did not show any EEG changes in the study. However, another study found that 5% of quetiapine users did experience EEG changes. These findings suggest that antipsychotics can have varying effects on EEG and should be monitored closely in patients taking them.

The inhibition of sexual behavior is caused by the activation of 5-HT2 receptors. However, this effect can be reversed by using 5-HT2 antagonists like cyproheptadine and 5-HT1a agonists like buspirone. These drugs are effective in treating sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs).

Antidepressants can cause sexual dysfunction as a side-effect, although the rates vary. The impact on sexual desire, arousal, and orgasm can differ depending on the type of antidepressant. It is important to rule out other causes and consider non-pharmacological strategies such as reducing the dosage of taking drug holidays. If necessary, switching to a lower risk antidepressant of using pharmacological options such as phosphodiesterase inhibitors of mirtazapine augmentation can be considered. The Maudsley Guidelines 14th Edition provides a helpful table outlining the risk of sexual dysfunction for different antidepressants.

The liver is responsible for metabolizing valproate, and drugs that disrupt the CYP enzymes can greatly impact its levels. Valproic acid and semi-sodium valproate are approved for treating bipolar disorder, while sodium valproate is solely approved for epilepsy.

Valproate: Forms, Doses, and Adverse Effects

Valproate comes in three forms: semi-sodium valproate, valproic acid, and sodium valproate. Semi-sodium valproate is a mix of sodium valproate and valproic acid and is licensed for acute mania associated with bipolar disorder. Valproic acid is also licensed for acute mania, but this is not consistent with the Maudsley Guidelines. Sodium valproate is licensed for epilepsy. It is important to note that doses of sodium valproate and semi-sodium valproate are not the same, with a slightly higher dose required for sodium valproate.

Valproate is associated with many adverse effects, including nausea, tremor, liver injury, vomiting/diarrhea, gingival hyperplasia, memory impairment/confusional state, somnolence, weight gain, anaemia/thrombocytopenia, alopecia (with curly regrowth), severe liver damage, and pancreatitis. Increased liver enzymes are common, particularly at the beginning of therapy, and tend to be transient. Vomiting and diarrhea tend to occur at the start of treatment and remit after a few days. Severe liver damage is most likely to occur in the first six months of therapy, with the maximum risk being between two and twelve weeks. The risk also declines with advancing age.

Valproate is a teratogen and should not be initiated in women of childbearing potential. Approximately 10% of children exposed to valproate monotherapy during pregnancy suffer from congenital malformations, with the risk being dose-dependent. The most common malformations are neural tube defects, facial dysmorphism, cleft lip and palate, craniostenosis, cardiac, renal and urogenital defects, and limb defects. There is also a dose-dependent relationship between valproate and developmental delay, with approximately 30-40% of children exposed in utero experiencing delay in their early development, such as talking and walking later, lower intellectual abilities, poor language skills, and memory problems. There is also a thought to be a 3-fold increase of autism in children exposed in utero.

The First Pass Effect in Psychiatric Drugs

The first-pass effect is a process in drug metabolism that significantly reduces the concentration of a drug before it reaches the systemic circulation. This phenomenon is related to the liver and gut wall, which absorb and metabolize the drug before it can enter the bloodstream. Psychiatric drugs are not exempt from this effect, and some undergo a significant reduction in concentration before reaching their target site. Examples of psychiatric drugs that undergo a significant first-pass effect include imipramine, fluphenazine, morphine, diazepam, and buprenorphine. On the other hand, some drugs undergo little to no first-pass effect, such as lithium and pregabalin.

Orally administered drugs are the most affected by the first-pass effect. However, there are other routes of administration that can avoid of partly avoid this effect. These include sublingual, rectal (partly avoids first pass), intravenous, intramuscular, transdermal, and inhalation. Understanding the first-pass effect is crucial in drug development and administration, especially in psychiatric drugs, where the concentration of the drug can significantly affect its efficacy and safety.

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

Antipsychotic use can lead to high levels of prolactin, which can cause amenorrhea. To address hyperprolactinemia, aripiprazole, quetiapine, and olanzapine are recommended. However, clozapine typically does not impact prolactin release.

Hyperprolactinemia is a potential side effect of antipsychotic medication, but it is rare with antidepressants. Dopamine inhibits prolactin, so dopamine antagonists, such as antipsychotics, can increase prolactin levels. The degree of prolactin elevation is dose-related, and some antipsychotics cause more significant increases than others. Hyperprolactinemia can cause symptoms such as galactorrhea, menstrual difficulties, gynecomastia, hypogonadism, and sexual dysfunction. Long-standing hyperprolactinemia in psychiatric patients can increase the risk of osteoporosis and breast cancer, although there is no conclusive evidence that antipsychotic medication increases the risk of breast malignancy and mortality. Some antipsychotics, such as clozapine and aripiprazole, have a low risk of causing hyperprolactinemia, while typical antipsychotics and risperidone have a high risk. Monitoring of prolactin levels is recommended before starting antipsychotic therapy and at three months and annually thereafter. Antidepressants rarely cause hyperprolactinemia, and routine monitoring is not recommended. Symptomatic hyperprolactinemia has been reported with most antidepressants, except for a few, such as mirtazapine, agomelatine, bupropion, and vortioxetine.

Pseudocholinesterase Deficiency

Pseudocholinesterase deficiency, also known as butyrylcholinesterase deficiency, is a medical condition that can lead to increased sensitivity to certain drugs. This condition affects approximately 1 in 3200 to 1 in 5000 people, with higher prevalence in certain populations such as the Persian Jewish community and Alaska Natives. Interestingly, this condition does not cause any noticeable symptoms until an abnormal drug reaction occurs.

It is important for individuals with pseudocholinesterase deficiency to avoid certain drugs, including donepezil, galantamine, procaine, succinylcholine, and pilocarpine. By avoiding these drugs, individuals with this condition can reduce their risk of experiencing adverse reactions.

Vigabatrin is an anticonvulsant drug that has been associated with irreversible concentric visual field loss in 30-50% of patients with long-term exposure. This visual field loss can vary in severity and is often asymptomatic, making regular visual field testing essential for patients taking this medication. It is important for healthcare providers to monitor patients closely for any signs of visual field loss and to consider alternative treatment options if necessary. For more information on anticonvulsant drugs, please refer to GP Notebook.

Antipsychotics and Sexual Dysfunction: Causes, Risks, and Management

Sexual dysfunction is a common side effect of antipsychotic medication, with the highest risk associated with risperidone and haloperidol due to their effect on prolactin levels. Clozapine, olanzapine, quetiapine, aripiprazole, asenapine, and lurasidone are associated with lower rates of sexual dysfunction. The Arizona Sexual Experiences Scale (ASEX) can be used to measure sexual dysfunction before and during treatment. Management options include excluding other causes, watchful waiting, dose reduction, switching to a lower risk agent, adding aripiprazole, considering an antidote medication, of using sildenafil for erectile dysfunction. It is important to address sexual dysfunction to improve quality of life and medication adherence.

The First Pass Effect in Psychiatric Drugs

The first-pass effect is a process in drug metabolism that significantly reduces the concentration of a drug before it reaches the systemic circulation. This phenomenon is related to the liver and gut wall, which absorb and metabolize the drug before it can enter the bloodstream. Psychiatric drugs are not exempt from this effect, and some undergo a significant reduction in concentration before reaching their target site. Examples of psychiatric drugs that undergo a significant first-pass effect include imipramine, fluphenazine, morphine, diazepam, and buprenorphine. On the other hand, some drugs undergo little to no first-pass effect, such as lithium and pregabalin.

Orally administered drugs are the most affected by the first-pass effect. However, there are other routes of administration that can avoid of partly avoid this effect. These include sublingual, rectal (partly avoids first pass), intravenous, intramuscular, transdermal, and inhalation. Understanding the first-pass effect is crucial in drug development and administration, especially in psychiatric drugs, where the concentration of the drug can significantly affect its efficacy and safety.

ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

Valproate is an anticonvulsant drug that is used to treat epilepsy and bipolar disorder. However, it can cause several side effects that patients should be aware of. Some of the common side effects of valproate include weight gain, nausea, vomiting, and hair loss. Patients may also experience easy bruising, tremors, and hepatic failure. In rare cases, valproate can cause pancreatitis, which is a serious inflammation of the pancreas. Patients should talk to their doctor if they experience any of these side effects while taking valproate.

ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

Mechanisms of Action of Different Antiepileptic Drugs

Pregabalin, Carbamazepine, Oxcarbazepine, Lamotrigine, Riluzole, and Valproate are all antiepileptic drugs that work through different mechanisms of action. Pregabalin specifically binds to the alpha 2 delta site of voltage-sensitive calcium channels, which prevents the release of neurotransmitters such as glutamate, thereby reducing pain and anxiety.

Carbamazepine, Oxcarbazepine, Lamotrigine, and Riluzole, on the other hand, act on the alpha unit of voltage-sensitive sodium channels. Valproate, Carbamazepine, Oxcarbazepine, Lamotrigine, and Riluzole all act on nonspecific voltage-sensitive sodium channels. Topiramate, Valproate, Carbamazepine, Oxcarbazepine, Lamotrigine, and Riluzole act on nonspecific voltage-sensitive calcium channels.

Finally, calcium itself acts on L-channel voltage-sensitive calcium channels. These different mechanisms of action allow for a variety of treatment options for epilepsy and other neurological disorders.

Out of these options, only the cytotoxic reaction is immunologic and specifically mediated by antibodies.

Adverse Drug Reactions (ADRs) refer to the harmful effects associated with the use of a medication at a normal dose. These reactions are classified into two types: Type A and Type B. Type A reactions can be predicted from the pharmacology of the drug and are dose-dependent, meaning they can be reversed by withdrawing the drug. On the other hand, Type B reactions cannot be predicted from the known pharmacology of the drug and include allergic reactions.

Type A reactions account for up to 80% of all ADRs, while Type B reactions are less common. Allergic reactions are a type of Type B reaction and are further subdivided by Gell and Coombs into four types: Type I (IgE-mediated) reactions, Type II (cytotoxic) reactions, Type III (immune complex) reactions, and Type IV (cell-mediated) reactions. Proper identification and management of ADRs are crucial in ensuring patient safety and optimizing treatment outcomes.

The symptoms observed in the presentation are indicative of serotonin syndrome, which can be caused by various medications such as antidepressants, lithium, opioids, olanzapine, and risperidone. However, benzodiazepines are not associated with serotonin syndrome and are actually used as part of the treatment.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

Pharmacokinetics is the study of how drugs are affected by the body. This includes how drugs are absorbed into the bloodstream, distributed throughout the body, metabolized into different forms, and eliminated from the body. The acronym ADME is often used to remember these processes. Absorption refers to the transportation of the drug from the site of administration to the bloodstream. Hydrophobic drugs are absorbed better than hydrophilic ones. Distribution refers to the movement of the drug from the bloodstream to other areas of the body. Metabolism involves the conversion of the drug into different forms, often to make it more easily excreted by the kidneys. This process occurs in two phases, involving reduction of hydrolysis in phase 1 and conjugation in phase 2. Excretion refers to the elimination of the drug from the body, which mainly occurs through the kidneys and biliary system.

Initially used to treat tuberculosis, iproniazid was found to have a positive impact on patients’ moods. Kline’s publication provided the first evidence supporting its effectiveness in treating depression.

A Historical Note on the Development of Zimelidine, the First Selective Serotonin Reuptake Inhibitor

In 1960s, evidence began to emerge suggesting a significant role of serotonin in depression. This led to the development of zimelidine, the first selective serotonin reuptake inhibitor (SSRI). Zimelidine was derived from pheniramine and was marketed in Europe in 1982. However, it was removed from the market in 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome.

Despite its short-lived availability, zimelidine paved the way for the development of other SSRIs such as fluoxetine, which was approved by the FDA in 1987 and launched in the US market in 1988 under the trade name Prozac. The development of SSRIs revolutionized the treatment of depression and other mood disorders, providing a safer and more effective alternative to earlier antidepressants such as the tricyclics and MAO inhibitors.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

Antipsychotics and Sexual Dysfunction: Causes, Risks, and Management

Sexual dysfunction is a common side effect of antipsychotic medication, with the highest risk associated with risperidone and haloperidol due to their effect on prolactin levels. Clozapine, olanzapine, quetiapine, aripiprazole, asenapine, and lurasidone are associated with lower rates of sexual dysfunction. The Arizona Sexual Experiences Scale (ASEX) can be used to measure sexual dysfunction before and during treatment. Management options include excluding other causes, watchful waiting, dose reduction, switching to a lower risk agent, adding aripiprazole, considering an antidote medication, of using sildenafil for erectile dysfunction. It is important to address sexual dysfunction to improve quality of life and medication adherence.

Due to their increased vulnerability to anticholinergic side effects, elderly individuals are at a higher risk of experiencing delirium. The first generation of H1 antihistamines, which have a greater tendency for anticholinergic side effects, are more likely to trigger delirium in the elderly. Benadryl, an over-the-counter medication in the UK used to treat hay fever, contains diphenhydramine as its active ingredient.

Antihistamines: Types and Uses

Antihistamines are drugs that block the effects of histamine, a neurotransmitter that regulates physiological function in the gut and potentiates the inflammatory and immune responses of the body. There are two types of antihistamines: H1 receptor blockers and H2 receptor blockers. H1 blockers are mainly used for allergic conditions and sedation, while H2 blockers are used for excess stomach acid.

There are also first and second generation antihistamines. First generation antihistamines, such as diphenhydramine and promethazine, have uses in psychiatry due to their ability to cross the blood brain barrier and their anticholinergic properties. They tend to be sedating and are useful for managing extrapyramidal side effects. Second generation antihistamines, such as loratadine and cetirizine, show limited penetration of the blood brain barrier and are less sedating.

It is important to note that there are contraindications to first-generation antihistamines, including benign prostatic hyperplasia, angle-closure glaucoma, and pyloric stenosis in infants. These do not apply to second-generation antihistamines.

While the majority of SSRIs are believed to have minimal impact on the QTc interval, studies have demonstrated that citalopram and escitalopram can lead to QTc prolongation.

Antidepressants and Their Cardiac Effects

SSRIs are generally recommended for patients with cardiac disease as they may protect against myocardial infarction (MI). Untreated depression worsens prognosis in cardiovascular disease. Post MI, SSRIs and mirtazapine have either a neutral of beneficial effect on mortality. Sertraline is recommended post MI, but other SSRIs and mirtazapine are also likely to be safe. However, citalopram is associated with Torsades de pointes (mainly in overdose). Bupropion, citalopram, escitalopram, moclobemide, lofepramine, and venlafaxine should be used with caution of avoided in those at risk of serious arrhythmia (those with heart failure, left ventricular hypertrophy, previous arrhythmia, of MI).

Tricyclic antidepressants (TCAs) have established arrhythmogenic activity which arises as a result of potent blockade of cardiac sodium channels and variable activity at potassium channels. ECG changes produced include PR, QRS, and QT prolongation and the Brugada syndrome. Lofepramine is less cardiotoxic than other TCAs and seems to lack the overdose arrhythmogenicity of other TCAs. QT changes are not usually seen at normal clinical doses of antidepressants (but can occur, particularly with citalopram/escitalopram). The arrhythmogenic potential of TCAs and other antidepressants is dose-related.

Overall, SSRIs are recommended for patients with cardiac disease, while caution should be exercised when prescribing TCAs and other antidepressants, especially in those at risk of serious arrhythmia. It is important to monitor patients closely for any cardiac effects when prescribing antidepressants.

Due to its long half-life, aripiprazole requires the longest time (2 weeks) to achieve a steady state among the atypical antipsychotics. As a result, any assessments of dosage adjustments should be delayed until 2-3 weeks after the changes have been made.

Antipsychotic Half-life and Time to Steady State

Antipsychotic medications are commonly used to treat various mental health conditions, including schizophrenia and bipolar disorder. Understanding the half-life and time to steady state of these medications is important for determining dosing and monitoring their effectiveness.

Aripiprazole has a half-life of 75 hours and takes approximately 2 weeks to reach steady state. Olanzapine has a half-life of 30 hours and takes about 1 week to reach steady state. Risperidone has a half-life of 20 hours when taken orally and takes 2-3 days to reach steady state. Clozapine and Amisulpride both have a half-life of 12 hours and take 2-3 days to reach steady state. Ziprasidone has a shorter half-life of 7 hours and takes 2-3 days to reach steady state. Quetiapine has the shortest half-life of 6 hours and also takes 2-3 days to reach steady state.

Knowing the half-life and time to steady state of antipsychotic medications can help healthcare providers determine the appropriate dosing and frequency of administration. It can also aid in monitoring the effectiveness of the medication and adjusting the treatment plan as needed.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

Benzodiazepines and Z-drugs (such as zopiclone and zolpidem) have a common mechanism of action on the GABA receptor. It is noteworthy that alcohol also affects this receptor, which explains the similar effects observed in alcohol and benzodiazepine use. Additionally, benzodiazepines play a role in managing alcohol withdrawal symptoms.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Given that olanzapine is a once daily medication, it is reasonable to estimate its half-life to fall within the range of 20-30 hours. As it happens, the actual half-life of olanzapine is 30 hours.

Antipsychotic Half-life and Time to Steady State

Antipsychotic medications are commonly used to treat various mental health conditions, including schizophrenia and bipolar disorder. Understanding the half-life and time to steady state of these medications is important for determining dosing and monitoring their effectiveness.

Aripiprazole has a half-life of 75 hours and takes approximately 2 weeks to reach steady state. Olanzapine has a half-life of 30 hours and takes about 1 week to reach steady state. Risperidone has a half-life of 20 hours when taken orally and takes 2-3 days to reach steady state. Clozapine and Amisulpride both have a half-life of 12 hours and take 2-3 days to reach steady state. Ziprasidone has a shorter half-life of 7 hours and takes 2-3 days to reach steady state. Quetiapine has the shortest half-life of 6 hours and also takes 2-3 days to reach steady state.

Knowing the half-life and time to steady state of antipsychotic medications can help healthcare providers determine the appropriate dosing and frequency of administration. It can also aid in monitoring the effectiveness of the medication and adjusting the treatment plan as needed.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Priapism: A Painful and Persistent Erection

Priapism is a condition characterized by a prolonged and painful erection, which can occur in males and even in the clitoris. Although rare, certain medications such as antipsychotics and antidepressants have been known to cause priapism. The primary mechanism behind this condition is alpha blockade, although other mechanisms such as serotonin-mediated pathways have also been suggested. Some of the drugs most commonly associated with priapism include Trazodone, Chlorpromazine, and Thioridazine. Treatment involves the use of alpha-adrenergic agonists, which can be administered orally of injected directly into the penis. Priapism is a serious condition that can lead to complications such as penile amputation, although such cases are extremely rare.

Antipsychotics and Their Effects on EEG

The use of antipsychotics has been found to have an impact on the EEG of patients taking them. A study conducted on the subject found that clozapine had the highest percentage of EEG changes at 47.1%, followed by olanzapine at 38.5%, risperidone at 28.0%, and typical antipsychotics at 14.5%. Interestingly, quetiapine did not show any EEG changes in the study. However, another study found that 5% of quetiapine users did experience EEG changes. These findings suggest that antipsychotics can have varying effects on EEG and should be monitored closely in patients taking them.

Antidepressants: Minimum Effective Doses

According to the Maudsley 13th, the following are the minimum effective doses for various antidepressants:

– Citalopram: 20 mg/day
– Fluoxetine: 20 mg/day
– Fluvoxamine: 50 mg/day
– Paroxetine: 20 mg/day
– Sertraline: 50 mg/day
– Mirtazapine: 30 mg/day
– Venlafaxine: 75 mg/day
– Duloxetine: 60 mg/day
– Agomelatine: 25 mg/day
– Moclobemide: 300 mg/day
– Trazodone: 150 mg/day

Note that these are minimum effective doses and may vary depending on individual factors and response to treatment. It is important to consult with a healthcare professional before starting of changing any medication regimen.

Patients with renal impairment should avoid taking amisulpride and sulpiride. This is because amisulpride is eliminated through the kidneys, and in cases of renal insufficiency, the dosage should be reduced, and intermittent treatment should be considered.

Prescribing medication for elderly individuals requires consideration of their unique pharmacokinetics and pharmacodynamics. As the body ages, changes in distribution, metabolism, and excretion can affect how medication is absorbed and processed. For example, reduced gastric acid secretion and motility can impact drug absorption, while a relative reduction of body water to body fat can alter the distribution of lipid soluble drugs. Additionally, hepatic metabolism of drugs decreases with age, and the kidneys become less effective, leading to potential accumulation of certain drugs.

In terms of pharmacodynamics, receptor sensitivity tends to increase during old age, meaning smaller doses may be needed. However, older individuals may also take longer to respond to treatment and have an increased incidence of side-effects. It is important to start with a lower dose and monitor closely when prescribing medication for elderly patients, especially considering the potential for interactions with other medications they may be taking.

While myoclonus can be scary for patients, it is typically not a danger to their lives. On the other hand, the muscle stiffness that occurs in serotonin syndrome is extremely severe and can result in the failure of multiple organs (Ahuja 2009).

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyperreflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

Antipsychotics can be classified in different ways, with the most common being typical (first generation) and atypical (second generation) types. Typical antipsychotics block dopamine (D2) receptors and have varying degrees of M1, Alpha-1, and H1 receptor blockade. Atypical antipsychotics have a lower propensity for extrapyramidal side-effects and are attributed to the combination of relatively lower D2 antagonism with 5HT2A antagonism. They are also classified by structure, with examples including phenothiazines, butyrophenones, thioxanthenes, diphenylbutylpiperidine, dibenzodiazepines, benzoxazoles, thienobenzodiazepine, substituted benzamides, and arylpiperidylindole (quinolone). Studies have found little evidence to support the superiority of atypicals over typicals in terms of efficacy, discontinuation rates, of adherence, with the main difference being the side-effect profile. The Royal College also favors classification by structure.

Bupropion is classified as a noradrenaline dopamine reuptake inhibitor (NDRI) and functions by elevating the levels of neurotransmitters such as noradrenaline and dopamine. It has been utilized as an antidepressant and a smoking cessation aid.

Some additional risk factors for QTc prolongation include being female and having a slow heart rate (bradycardia).

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

Out of the given options, amisulpride is the most suitable medication as it is not extensively metabolized by the liver. However, it should be avoided in individuals with established renal failure as a normal glomerular filtration rate is considered to be >90 ml/min/1.73m2.

Hepatic Impairment: Recommended Drugs

Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

Mood stabilizers: Lithium

Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

Pharmacokinetics in Pregnancy

During pregnancy, there are significant changes in maternal physiology that can affect the pharmacokinetics of drugs. These changes are most pronounced in the third trimester. One of the most notable changes is an increase in plasma volume, which can lead to haemodilution and a decrease in the concentration of plasma albumin. As a result, the total plasma concentrations of albumin-bound drugs may decrease during pregnancy. Additionally, lipophilic drugs may have an increased volume of distribution due to the increase in plasma volume.

Progesterone levels are also elevated during pregnancy, which can lead to delayed gastric emptying and reduced small intestine motility. This may affect the absorption of drugs, but the overall impact on bioavailability is likely to be relatively small.

The activity of hepatic drug-metabolizing enzymes can also change during pregnancy. Estrogens and progesterone can induce some CYP enzymes and inhibit others, leading to altered drug metabolism.

Finally, renal blood flow and the glomerular filtration rate increase during pregnancy, which can enhance the elimination of some drugs. The GFR can increase by up to 50% during pregnancy. These changes in pharmacokinetics during pregnancy must be taken into account when prescribing drugs to pregnant women.

The Bazett formula adjusts the QT interval for heart rate by taking the square root of the R-R interval and dividing the QT interval by it.

QTc Prolongation: Risks and Identification

The QT interval is a measure of the time it takes for the ventricles to repolarize and is calculated from the beginning of the QRS complex to the end of the T wave. However, the QT interval varies with the heart rate, making it difficult to use a single number as a cut-off for a prolonged QT. Instead, a corrected QT interval (QTc) is calculated for each heart rate using various formulas. A QTc over the 99th percentile is considered abnormally prolonged, with approximate values of 470 ms for males and 480 ms for females.

Prolonged QT intervals can lead to torsade de pointes (TdP), a polymorphic ventricular tachycardia that can be fatal if it degenerates into ventricular fibrillation. TdP is characterized by a twisting of the QRS complexes around an isoelectric line and is often asymptomatic but can also be associated with syncope and death. An accurate diagnosis requires an ECG to be recorded during the event. It is important to note that an increase in the QT interval due to a new conduction block should not be considered indicative of acquired LQTS and risk for TdP.

Antipsychotic drugs are known to cause weight gain, but some more than others. The reason for this is not due to a direct metabolic effect, but rather an increase in appetite and a decrease in activity levels. The risk of weight gain appears to be linked to clinical response. There are several suggested mechanisms for this, including antagonism of certain receptors and hormones that stimulate appetite. The risk of weight gain varies among different antipsychotics, with clozapine and olanzapine having the highest risk. Management strategies for antipsychotic-induced weight gain include calorie restriction, low glycemic index diet, exercise, and switching to an alternative antipsychotic. Aripiprazole, ziprasidone, and lurasidone are recommended as alternative options. Other options include aripiprazole augmentation, metformin, orlistat, liraglutide, and topiramate.

Tricyclic antidepressants are known to cause various side effects, which can be attributed to their mechanisms of action. These include antimuscarinic effects, which can lead to dry mouth and urinary retention, antihistaminergic effects, which can cause weight gain and drowsiness, antiadrenergic effects, which can result in postural hypotension, sexual dysfunction, and cognitive impairment, and antiserotonergic effects, which can lead to weight gain. Additionally, tricyclic antidepressants can cause cardiotoxicity and reduce the seizure threshold due to their membrane stabilizing effects. Other important side effects of these drugs include arrhythmias and ECG changes, black tongue, tremor, altered liver function tests, paralytic ileus, and neuroleptic malignant syndrome. Black hairy tongue, a harmless condition where the tongue appears black and hairy due to elongated filiform papillae, is also a possible side effect of tricyclic antidepressants.

Water intoxication can cause polyuria and dilutional hyponatremia, but it does not typically lead to renal impairment. It is important to differentiate this condition from nephrogenic diabetes insipidus, which can develop in a significant percentage of patients on long-term lithium therapy and may present with nocturia as an early sign. While elevated calcium levels may occur in some patients on lithium, hyperparathyroidism is not a common clinical symptom. Tubulointerstitial nephritis is a rare complication of lithium therapy. The syndrome of inappropriate ADH secretion is not typically associated with polyuria of renal impairment and is not commonly linked to lithium therapy.

Aripiprazole exhibits partial agonism at D2 receptors and acts as an agonist at 5HT1A receptors while antagonizing 5HT2A receptors.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Promethazine is utilized for its sedative properties in cases of agitation due to the fact that first generation H1 antihistamines easily penetrate the BBB and induce drowsiness.

Antihistamines: Types and Uses

Antihistamines are drugs that block the effects of histamine, a neurotransmitter that regulates physiological function in the gut and potentiates the inflammatory and immune responses of the body. There are two types of antihistamines: H1 receptor blockers and H2 receptor blockers. H1 blockers are mainly used for allergic conditions and sedation, while H2 blockers are used for excess stomach acid.

There are also first and second generation antihistamines. First generation antihistamines, such as diphenhydramine and promethazine, have uses in psychiatry due to their ability to cross the blood brain barrier and their anticholinergic properties. They tend to be sedating and are useful for managing extrapyramidal side effects. Second generation antihistamines, such as loratadine and cetirizine, show limited penetration of the blood brain barrier and are less sedating.

It is important to note that there are contraindications to first-generation antihistamines, including benign prostatic hyperplasia, angle-closure glaucoma, and pyloric stenosis in infants. These do not apply to second-generation antihistamines.

Mirtazapine and Mianserin are significant NaSSA’s (Noradrenergic and specific serotonergic antidepressants) that function by blocking adrenergic and serotonergic receptors. In contrast to the majority of antidepressants, they do not impact the reuptake of serotonin.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Antidepressants typically interfere with the natural pattern of sleep, especially by reducing REM sleep. However, Agomelatine has been found to enhance disrupted sleep-wake cycles in individuals with major depressive disorder.

Agomelatine: A New Drug for Depression Treatment

Agomelatine is a recently developed medication that is used to treat depression. Its mechanism of action involves acting as an agonist at melatonin M1 and M2 receptors, while also acting as an antagonist at 5HT2C receptors. The effects of melatonin appear to promote sleep, while the 5HT2C antagonism leads to the release of dopamine and norepinephrine in the frontal cortex. Interestingly, serotonin levels do not appear to be affected by this medication.

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

Antipsychotic drugs such as chlorpromazine have an antidopaminergic effect, which can lead to hyperprolactinemia and hypogonadism. Additionally, they can cause a serious condition called neuroleptic malignant syndrome, which is characterized by hyperthermia, muscular rigidity, and altered consciousness. This syndrome is caused by the blocking of dopamine receptors and is more commonly associated with typical antipsychotics like chlorpromazine, haloperidol, and trifluoperazine. However, cases have also been reported with most atypical antipsychotic agents.

In the treatment of Alzheimer’s disease, acetylcholinesterase inhibitors such as galantamine are utilized to enhance central acetylcholine levels. Although they share this common mechanism of action, there are variations in how they function. Unlike galantamine, rivastigmine has the ability to inhibit butyrylcholinesterase.

While antipsychotics, tricyclic antidepressants, and citalopram are known to cause QTc prolongation and require ECG monitoring, they are not the only drugs that can cause this condition. However, in psychiatric practice, they are the most commonly prescribed drugs associated with QTc prolongation. It is important to note that clarithromycin is a high-risk drug for QTc prolongation, unlike the other drugs listed, which are considered low risk.

Prescribing in the Elderly: Iatrogenic Consequences

Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

Medications Linked to Delirium and Other Cognitive Disorders

Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

Medications Linked to Mood Changes

The following medications are well known to precipitate mood changes:

– Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
– Interferon-a is capable of inducing depressive symptoms.
– Digoxin is capable of inducing depressive symptoms.
– Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
– Antidepressants can precipitate mania.

Medications Linked to Psychosis

The following medications are well known to precipitate psychosis:

– Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
– Corticosteroids

Medications Linked to Anxiety

The following medications are well known to precipitate anxiety:

– Stimulants
– β adrenergic inhalers

Prescribing in the Elderly: Iatrogenic Consequences

Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

Medications Linked to Delirium and Other Cognitive Disorders

Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

Medications Linked to Mood Changes

The following medications are well known to precipitate mood changes:

– Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
– Interferon-a is capable of inducing depressive symptoms.
– Digoxin is capable of inducing depressive symptoms.
– Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
– Antidepressants can precipitate mania.

Medications Linked to Psychosis

The following medications are well known to precipitate psychosis:

– Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
– Corticosteroids

Medications Linked to Anxiety

The following medications are well known to precipitate anxiety:

– Stimulants
– β adrenergic inhalers

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

Antidepressants can cause sexual dysfunction as a side-effect, although the rates vary. The impact on sexual desire, arousal, and orgasm can differ depending on the type of antidepressant. It is important to rule out other causes and consider non-pharmacological strategies such as reducing the dosage of taking drug holidays. If necessary, switching to a lower risk antidepressant of using pharmacological options such as phosphodiesterase inhibitors of mirtazapine augmentation can be considered. The Maudsley Guidelines 14th Edition provides a helpful table outlining the risk of sexual dysfunction for different antidepressants.

According to a recent study by Ran (2019), lithium carbonate has been found to have a neuroprotective effect in individuals who have experienced a stroke. The study conducted exploratory analyses of neuroanatomical and cognitive outcomes in a poststroke population. It is interesting to note that while lithium is contraindicated in individuals with Addison’s disease, it is only cautioned in individuals with QT prolongation. Hypothyroidism (untreated) is also a contraindication for lithium. Addison’s disease is a condition characterized by inadequate production of cortisol and aldosterone by the adrenal cortex, leading to symptoms such as fatigue, gastrointestinal abnormalities, changes in skin pigmentation, and mood changes. In some cases, acute adrenal failure can occur, which is a serious condition that develops rapidly. The cause of Addison’s disease is often due to the body’s immune system mistakenly attacking the adrenal glands, causing progressive damage to the adrenal cortex.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

Antipsychotics can be classified in different ways, with the most common being typical (first generation) and atypical (second generation) types. Typical antipsychotics block dopamine (D2) receptors and have varying degrees of M1, Alpha-1, and H1 receptor blockade. Atypical antipsychotics have a lower propensity for extrapyramidal side-effects and are attributed to the combination of relatively lower D2 antagonism with 5HT2A antagonism. They are also classified by structure, with examples including phenothiazines, butyrophenones, thioxanthenes, diphenylbutylpiperidine, dibenzodiazepines, benzoxazoles, thienobenzodiazepine, substituted benzamides, and arylpiperidylindole (quinolone). Studies have found little evidence to support the superiority of atypicals over typicals in terms of efficacy, discontinuation rates, of adherence, with the main difference being the side-effect profile. The Royal College also favors classification by structure.

The mechanism of action of phenytoin involves the stabilization of sodium channels.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

A Historical Note on the Development of Zimelidine, the First Selective Serotonin Reuptake Inhibitor

In 1960s, evidence began to emerge suggesting a significant role of serotonin in depression. This led to the development of zimelidine, the first selective serotonin reuptake inhibitor (SSRI). Zimelidine was derived from pheniramine and was marketed in Europe in 1982. However, it was removed from the market in 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome.

Despite its short-lived availability, zimelidine paved the way for the development of other SSRIs such as fluoxetine, which was approved by the FDA in 1987 and launched in the US market in 1988 under the trade name Prozac. The development of SSRIs revolutionized the treatment of depression and other mood disorders, providing a safer and more effective alternative to earlier antidepressants such as the tricyclics and MAO inhibitors.

Porphyria: The Little Imitator

Porphyria is a medical condition that is often referred to as the little imitator because it can mimic various common psychiatric presentations. This condition can be triggered by the use of certain psychotropic drugs, including barbiturates, benzodiazepines, sulpiride, and some mood stabilizers.

Porphyria can manifest in different ways, and it is important to be aware of the symptoms. These may include abdominal pain, mental state changes, constipation, vomiting, and muscle weakness.

The half life of fluoxetine, the longest lasting SSRI, is four to six days, while its active metabolite, norfluoxetine, has a half life of four to 16 days. Citalopram has a half life of 33 hours, escitalopram has a half life of 30 hours, paroxetine has a half life of 24 hours, and sertraline has a half life of 26 hours.

Prescribing medication for elderly individuals requires consideration of their unique pharmacokinetics and pharmacodynamics. As the body ages, changes in distribution, metabolism, and excretion can affect how medication is absorbed and processed. For example, reduced gastric acid secretion and motility can impact drug absorption, while a relative reduction of body water to body fat can alter the distribution of lipid soluble drugs. Additionally, hepatic metabolism of drugs decreases with age, and the kidneys become less effective, leading to potential accumulation of certain drugs.

In terms of pharmacodynamics, receptor sensitivity tends to increase during old age, meaning smaller doses may be needed. However, older individuals may also take longer to respond to treatment and have an increased incidence of side-effects. It is important to start with a lower dose and monitor closely when prescribing medication for elderly patients, especially considering the potential for interactions with other medications they may be taking.

The half-life of a drug is the time taken for its concentration to fall to one half of its value. Drugs with long half-lives may require a loading dose to achieve therapeutic plasma concentrations rapidly. It takes about 4.5 half-lives to reach steady state plasma levels. Most drugs follow first order kinetics, where a constant fraction of the drug in the body is eliminated per unit time. However, some drugs may follow zero order kinetics, where the plasma concentration of the drug decreases at a constant rate, despite the concentration of the drug. For drugs with nonlinear kinetics of dose-dependent kinetics, the relationship between the AUC of CSS and dose is not linear, and the kinetic parameters may vary depending on the administered dose.

To avoid a severe drug reaction, it is important to wait at least two weeks after stopping a monoamine oxidase inhibitor (MAOI) before starting a selective serotonin reuptake inhibitor (SSRI). MAOIs can inhibit the enzymes responsible for breaking down certain neurotransmitters, such as noradrenaline and 5-hydroxytryptamine (5HT), as well as tyramine. It may take up to two weeks for these enzymes to resume normal activity after stopping an MAOI, and starting an SSRI during this time can be dangerous.

Individuals with hepatic impairment should avoid taking agomelatine and duloxetine due to contraindications. It is recommended to avoid sedative TCAs, such as trimipramine, imipramine, dothiepin, and amitriptyline.

Hepatic Impairment: Recommended Drugs

Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

Mood stabilizers: Lithium

Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

The available evidence is of poor quality and does not support an increased risk of delirium associated with digoxin.

Prescribing in the Elderly: Iatrogenic Consequences

Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

Medications Linked to Delirium and Other Cognitive Disorders

Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

Medications Linked to Mood Changes

The following medications are well known to precipitate mood changes:

– Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
– Interferon-a is capable of inducing depressive symptoms.
– Digoxin is capable of inducing depressive symptoms.
– Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
– Antidepressants can precipitate mania.

Medications Linked to Psychosis

The following medications are well known to precipitate psychosis:

– Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
– Corticosteroids

Medications Linked to Anxiety

The following medications are well known to precipitate anxiety:

– Stimulants
– β adrenergic inhalers

Although many drugs are metabolized by CYP1A2, grapefruit juice does not have a significant effect on the metabolism of lithium, as the majority of lithium is excreted without undergoing significant metabolic changes.

The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

Tardive Dyskinesia: Symptoms, Causes, Risk Factors, and Management

Tardive dyskinesia (TD) is a condition that affects the face, limbs, and trunk of individuals who have been on neuroleptics for months to years. The movements fluctuate over time, increase with emotional arousal, decrease with relaxation, and disappear with sleep. The cause of TD remains theoretical, but the postsynaptic dopamine (D2) receptor supersensitivity hypothesis is the most persistent. Other hypotheses include the presynaptic dopaminergic/noradrenergic hyperactivity hypothesis, the cholinergic interneuron burnout hypothesis, the excitatory/oxidative stress hypothesis, and the synaptic plasticity hypothesis. Risk factors for TD include advancing age, female sex, ethnicity, longer illness duration, intellectual disability and brain damage, negative symptoms in schizophrenia, mood disorders, diabetes, smoking, alcohol and substance misuse, FGA vs SGA treatment, higher antipsychotic dose, anticholinergic co-treatment, and akathisia.

Management options for TD include stopping any anticholinergic, reducing antipsychotic dose, changing to an antipsychotic with lower propensity for TD, and using tetrabenazine, vitamin E, of amantadine as add-on options. Clozapine is the antipsychotic most likely to be associated with resolution of symptoms. Vesicular monoamine transporter type 2 (VMAT2) inhibitors are agents that cause a depletion of neuroactive peptides such as dopamine in nerve terminals and are used to treat chorea due to neurodegenerative diseases of dyskinesias due to neuroleptic medications (tardive dyskinesia).

Discontinuation symptoms are common when stopping most antidepressants, typically appearing within 5 days of treatment cessation. However, these symptoms are more likely to occur with short half-life drugs like paroxetine, especially when doses are missed. It’s important to note that discontinuing paroxetine may lead to suicidal thoughts, so patients should be informed of the potential risks associated with poor compliance.

Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

Stevens-Johnson syndrome is a severe skin condition that can be caused by medication use of infection. Anticonvulsants, particularly lamotrigine, are often the cause. Symptoms include fever, sore throat, fatigue, and the appearance of ulcers and lesions in the mucous membranes. A rash of round lesions also appears on the face, trunk, arms, legs, and soles of the feet. It is a life-threatening condition that requires immediate medical attention.

Bazett’s formula adjusts the QT interval to account for variations in heart rate.

QTc Prolongation: Risks and Identification

The QT interval is a measure of the time it takes for the ventricles to repolarize and is calculated from the beginning of the QRS complex to the end of the T wave. However, the QT interval varies with the heart rate, making it difficult to use a single number as a cut-off for a prolonged QT. Instead, a corrected QT interval (QTc) is calculated for each heart rate using various formulas. A QTc over the 99th percentile is considered abnormally prolonged, with approximate values of 470 ms for males and 480 ms for females.

Prolonged QT intervals can lead to torsade de pointes (TdP), a polymorphic ventricular tachycardia that can be fatal if it degenerates into ventricular fibrillation. TdP is characterized by a twisting of the QRS complexes around an isoelectric line and is often asymptomatic but can also be associated with syncope and death. An accurate diagnosis requires an ECG to be recorded during the event. It is important to note that an increase in the QT interval due to a new conduction block should not be considered indicative of acquired LQTS and risk for TdP.

If a patient develops NMS, they may still require antipsychotic medication. However, it is recommended to stop antipsychotics for at least 5 days, and ideally longer. When restarting antipsychotics, it should be done slowly and at low doses, with close monitoring of blood pressure and temperature.

Anticholinergic drugs are believed to worsen NMS, possibly due to their effect on reducing sweating and exacerbating hyperthermia. However, there is no direct causal relationship between anticholinergics and NMS.

In cases where an alternative antipsychotic is needed, those with low dopamine affinity should be considered. These include clozapine, quetiapine, and aripiprazole.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

SNRIs include duloxetine and venlafaxine.

Antidepressants: Mechanism of Action

Antidepressants are a class of drugs used to treat depression and other mood disorders. The mechanism of action of antidepressants varies depending on the specific drug. Here are some examples:

Mirtazapine is a noradrenaline and serotonin specific antidepressant (NaSSa). It works by blocking certain receptors in the brain, including 5HT-1, 5HT-2, 5HT-3, and H1 receptors. It also acts as a presynaptic alpha 2 antagonist, which stimulates the release of noradrenaline and serotonin.

Venlafaxine and duloxetine are both serotonin and noradrenaline reuptake inhibitors (SNRIs). They work by blocking the reuptake of these neurotransmitters, which increases their availability in the brain.

Reboxetine is a noradrenaline reuptake inhibitor (NRI). It works by blocking the reuptake of noradrenaline, which increases its availability in the brain.

Bupropion is a noradrenaline and dopamine reuptake inhibitor (NDRI). It works by blocking the reuptake of these neurotransmitters, which increases their availability in the brain.

Trazodone is a weak serotonin reuptake inhibitor (SRI) and 5HT agonist. It works by increasing the availability of serotonin in the brain.

St John’s Wort is a natural supplement that has been used to treat depression. It has a weak monoamine oxidase inhibitor (MAOI) effect and a weak SNRI effect.

In summary, antidepressants work by increasing the availability of certain neurotransmitters in the brain, such as serotonin, noradrenaline, and dopamine. The specific mechanism of action varies depending on the drug.

Antipsychotics and Sexual Dysfunction: Causes, Risks, and Management

Sexual dysfunction is a common side effect of antipsychotic medication, with the highest risk associated with risperidone and haloperidol due to their effect on prolactin levels. Clozapine, olanzapine, quetiapine, aripiprazole, asenapine, and lurasidone are associated with lower rates of sexual dysfunction. The Arizona Sexual Experiences Scale (ASEX) can be used to measure sexual dysfunction before and during treatment. Management options include excluding other causes, watchful waiting, dose reduction, switching to a lower risk agent, adding aripiprazole, considering an antidote medication, of using sildenafil for erectile dysfunction. It is important to address sexual dysfunction to improve quality of life and medication adherence.

The half-life of a drug is the time taken for its concentration to fall to one half of its value. Drugs with long half-lives may require a loading dose to achieve therapeutic plasma concentrations rapidly. It takes about 4.5 half-lives to reach steady state plasma levels. Most drugs follow first order kinetics, where a constant fraction of the drug in the body is eliminated per unit time. However, some drugs may follow zero order kinetics, where the plasma concentration of the drug decreases at a constant rate, despite the concentration of the drug. For drugs with nonlinear kinetics of dose-dependent kinetics, the relationship between the AUC of CSS and dose is not linear, and the kinetic parameters may vary depending on the administered dose.

Varenicline is a medication that helps people quit smoking by partially activating specific nicotine receptors in the body.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Bupropion is classified as a norepinephrine dopamine reuptake inhibitor (NDRI) and is used in smoking cessation by increasing dopamine levels in the limbic area, which reduces cravings. Other types of reuptake inhibitors include norepinephrine reuptake inhibitors (NRIs) such as atomoxetine and reboxetine, selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, citalopram, escitalopram, sertraline, and fluvoxamine, serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, desvenlafaxine, duloxetine, and milnacipran, and tricyclic antidepressants such as amitriptyline, nortriptyline, trazodone, and nefazodone.

Although the occurrence of the post-injection syndrome is rare, patients must still be observed for three hours after receiving the depot injection.

, coma, respiratory depression (rare)

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

Buspirone is a type of anti-anxiety medication that belongs to the azapirone (azaspirodecanedione) class of drugs. It is used to treat the same conditions as benzodiazepines. Unlike benzodiazepines, buspirone is a partial agonist of the serotonin 5HT1A receptor and does not cause sedation, physical dependence, of psychomotor impairment. However, it may cause side effects such as dizziness, headache, excitement, and nausea. Other less common side effects include dry mouth, tachycardia/palpitations/chest pain, drowsiness/confusion, seizures, fatigue, and sweating. Buspirone is not recommended for individuals with epilepsy, severe hepatic impairment, moderate to severe renal impairment, during pregnancy, of while breastfeeding.

Sertraline is the preferred medication for treating post-MI depression as it has minimal impact on heart rate, blood pressure, and the QTc interval. Tricyclics are not recommended due to their potential to cause postural hypotension, increased heart rate, and QTc interval prolongation. Fluoxetine may be used with caution as it has a slight effect on heart rate but does not significantly affect blood pressure of the QTc interval. Trazodone should be used with care as it can cause significant postural hypotension and QTc interval prolongation in post-MI patients. Venlafaxine should be avoided in these patients as it can increase blood pressure, particularly at higher doses.

Methylphenidate commonly causes a decrease in appetite, while the other listed side-effects are considered rare of uncommon.

ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

Haemochromatosis is a genetic condition that causes a gradual accumulation of iron in the body over time. If left untreated, this excess iron can be deposited in organs like the liver and heart, potentially leading to organ failure. Treatment typically involves phlebotomy, which removes excess iron from the body and helps maintain healthy iron levels.

Hepatic Impairment: Recommended Drugs

Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

Mood stabilizers: Lithium

Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

Priapism: A Painful and Persistent Erection

Priapism is a condition characterized by a prolonged and painful erection, which can occur in males and even in the clitoris. Although rare, certain medications such as antipsychotics and antidepressants have been known to cause priapism. The primary mechanism behind this condition is alpha blockade, although other mechanisms such as serotonin-mediated pathways have also been suggested. Some of the drugs most commonly associated with priapism include Trazodone, Chlorpromazine, and Thioridazine. Treatment involves the use of alpha-adrenergic agonists, which can be administered orally of injected directly into the penis. Priapism is a serious condition that can lead to complications such as penile amputation, although such cases are extremely rare.

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

Non-compliance is often caused by weight gain.

Antidepressants and Weight Gain

Studies suggest that certain types of antidepressants, such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), may be more likely to cause weight gain than newer antidepressants like selective serotonin reuptake inhibitors (SSRIs). However, mirtazapine, a newer antidepressant, may have a similar risk for weight gain as TCAs. Among SSRIs, paroxetine may have a higher risk for weight gain during long-term treatment compared to other SSRIs. On the other hand, bupropion and nefazodone may have a lower risk for weight gain than SSRIs in the long term.

Phase I metabolism involves the conversion of a parent drug into active metabolites that are polar, whereas phase II metabolism converts the parent drug into inactive metabolites that are also polar.

Understanding Biotransformation: A Metabolic Process for Excretion

Biotransformation is a metabolic process that occurs primarily in the liver, but also in other organs such as the kidneys, intestine, adipose, skin, and lungs. Its main function is to facilitate the excretion of both exogenous and endogenous substances by altering their chemical structures through a series of reactions. Enzymes found in the cytoplasm, endoplasmic reticulum, and mitochondria of cells catalyze these reactions, which can cause the substrate to become inactive, active, of even toxic.

Biotransformation is divided into three phases. Phase I reactions involve oxidation, reduction, of hydrolysis of the drug, yielding a polar, water-soluble metabolite that is often still active. Phase II reactions consist of adding hydrophilic groups to the original molecule, a toxic intermediate, of a nontoxic metabolite formed in phase I, to increase its polarity. The most common method is conjugation with glucuronic acid, but other groups such as sulphate, amino acids, acetate, and methyl can also be added. Phase III reactions occur post-phase II, where a chemical substance can undergo further metabolism and excretion through active transport into the urinary of hepatobiliary system.

Understanding biotransformation is crucial in pharmacology and toxicology, as it affects the efficacy and toxicity of drugs and other substances. By facilitating the excretion of these substances, biotransformation helps maintain homeostasis in the body and prevent accumulation of potentially harmful compounds.

The other conditions listed require careful consideration when using selective serotonin reuptake inhibitors (SSRIs), while acute mania is an absolute contraindication.

The TCAs that are considered the most hazardous in overdose are amitriptyline and dosulepin (dothiepin).

Tricyclic Antidepressants: Uses, Types, and Side-Effects

Tricyclic antidepressants (TCAs) are a type of medication used for depression and neuropathic pain. However, due to their side-effects and toxicity in overdose, they are not commonly used for depression anymore. TCAs can be divided into two types: first generation (tertiary amines) and second generation (secondary amines). The secondary amines have a lower side effect profile and act primarily on noradrenaline, while the tertiary amines boost serotonin and noradrenaline.

Some examples of secondary amines include desipramine, nortriptyline, protriptyline, and amoxapine. Examples of tertiary amines include amitriptyline, lofepramine, imipramine, clomipramine, dosulepin (dothiepin), doxepin, trimipramine, and butriptyline. Common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, and urinary retention.

Low-dose amitriptyline is commonly used for neuropathic pain and prophylaxis of headache. Lofepramine has a lower incidence of toxicity in overdose. However, amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose. It is important to consult with a healthcare provider before taking any medication and to follow their instructions carefully.

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Porphyria: The Little Imitator

Porphyria is a medical condition that is often referred to as the little imitator because it can mimic various common psychiatric presentations. This condition can be triggered by the use of certain psychotropic drugs, including barbiturates, benzodiazepines, sulpiride, and some mood stabilizers.

Porphyria can manifest in different ways, and it is important to be aware of the symptoms. These may include abdominal pain, mental state changes, constipation, vomiting, and muscle weakness.

Individuals of African and African-American descent exhibit the greatest prevalence of deficient CYP2D6 metabolism, resulting in a higher likelihood of being poor metabolisers. Codeine is classified as a prodrug, necessitating initial metabolism (specifically by CYP2D6) before it can produce pain-relieving effects.

The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

There is controversy surrounding the question, likely due to its poor wording. However, some sources suggest that the correct answer is EEG. This may be based on a one-time recommendation in the Frith Prescribing Guidelines from 2005, which suggests that an EEG is necessary before starting lithium due to its potential to lower the seizure threshold, which is particularly relevant for individuals with LD who are prone to seizures. However, this recommendation has not been supported by NICE, the BNF, of the Maudsley Guidelines, so it should be viewed with caution. NICE and the Maudsley do recommend that all individuals have an ECG before starting lithium, so choosing that answer would be a safe choice.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

Most antidepressants and stimulants target monoamine transporters, which are crucial molecular targets. These transporters are also targeted by 30% of all psychotropic drugs. Another 30% of psychotropic drugs target G-protein-linked receptors, while enzymes are targeted by about 10% of these drugs. Monoamine oxidase inhibitors (MAOIs) are a type of antidepressant that targets the enzyme monoamine oxidase. Ligand-gated and voltage-gated ion channels are targeted by 20% and 10% of all psychotropic drugs, respectively.

While certain factors in his medical history, such as smoking, may heighten the likelihood of a cardiac event, it is solely his bradycardia that is associated with QTc prolongation.

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

Due to its low therapeutic index, lithium necessitates monitoring.

Narrow Therapeutic Index Drugs

Narrow therapeutic index (NTI) drugs are medications that have a small difference between the amount that causes a therapeutic effect and the amount that causes toxicity. In other words, the therapeutic index (TI) of these drugs is narrow. The TI is a ratio that compares the blood concentration at which a drug causes a therapeutic effect to the amount that causes death of toxicity.

In clinical practice, the TI is the range of doses at which a medication appeared to be effective in clinical trials for a median of participants without unacceptable adverse effects. For most drugs, this range is wide enough, and the maximum plasma concentration of the drug achieved when the recommended doses of a drug are prescribed lie sufficiently above the minimum therapeutic concentration and sufficiently below the toxic concentration.

However, some drugs have a narrow therapeutic index, which means that even small changes in dose of blood concentration can lead to serious adverse effects. The US Food and Drug Administration (FDA) defines a drug product as having an NTI when there is less than a twofold difference in the minimum toxic concentrations and minimum effective concentrations in the blood and safe and effective use of the drug requires careful titration and patient monitoring.

Examples of drugs with a narrow therapeutic index include carbamazepine, lithium, phenytoin, warfarin, digoxin, and gentamicin. These drugs require close monitoring to ensure that the blood concentration remains within the therapeutic range and does not reach toxic levels.

Alcohol withdrawal is a common issue in the UK, and Chlordiazepoxide (Librium) is a benzodiazepine that is frequently used to treat it. This medication is safe, effective, and allows for flexible dosing. Acamprosate is another medication that is licensed for the treatment of alcohol cravings, while Carbamazepine may be used in cases where there is a risk of withdrawal seizures. Chlormethiazole, also known as Heminevrin, was once widely used for alcohol withdrawal but is now less commonly used due to its relative toxicity. Chlorpromazine, a typical antipsychotic, is not typically used in uncomplicated cases of alcohol withdrawal.

Younger patients, males, and smokers typically exhibit lower plasma levels of clozapine, while the Asian population tends to have higher levels.

ADRs only occur when medications are used at ABNORMAL doses. (FALSE)

Adverse Drug Reactions (ADRs) refer to the harmful effects associated with the use of a medication at a normal dose. These reactions are classified into two types: Type A and Type B. Type A reactions can be predicted from the pharmacology of the drug and are dose-dependent, meaning they can be reversed by withdrawing the drug. On the other hand, Type B reactions cannot be predicted from the known pharmacology of the drug and include allergic reactions.

Type A reactions account for up to 80% of all ADRs, while Type B reactions are less common. Allergic reactions are a type of Type B reaction and are further subdivided by Gell and Coombs into four types: Type I (IgE-mediated) reactions, Type II (cytotoxic) reactions, Type III (immune complex) reactions, and Type IV (cell-mediated) reactions. Proper identification and management of ADRs are crucial in ensuring patient safety and optimizing treatment outcomes.

Paul Charpentier synthesized the antipsychotic chlorpromazine in 1951, which led to the creation of additional phenothiazines and related compounds like thioxanthenes (flupentixol). Later on, alternative structures were discovered, such as butyrophenones (haloperidol), diphenylbutylpiperidine (Pimozide), and substituted benzamides (Sulpiride).

The inhibition of sexual behavior is caused by the activation of 5-HT2 receptors. However, this effect can be reversed by using 5-HT2 antagonists like cyproheptadine and 5-HT1a agonists like buspirone. These drugs are effective in treating sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs).

Antidepressants can cause sexual dysfunction as a side-effect, although the rates vary. The impact on sexual desire, arousal, and orgasm can differ depending on the type of antidepressant. It is important to rule out other causes and consider non-pharmacological strategies such as reducing the dosage of taking drug holidays. If necessary, switching to a lower risk antidepressant of using pharmacological options such as phosphodiesterase inhibitors of mirtazapine augmentation can be considered. The Maudsley Guidelines 14th Edition provides a helpful table outlining the risk of sexual dysfunction for different antidepressants.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

The patient’s reported symptoms are indicative of postural hypotension, which is likely a side effect of the olanzapine medication they were given.

Maudsley Guidelines: Antipsychotics for Postural Hypotension

When postural hypotension is a concern, it may be necessary to switch to an antipsychotic that is less likely to cause this side effect. The following antipsychotics are recommended by the Maudsley Guidelines:

– Amisulpride
– Aripiprazole
– Haloperidol
– Sulpiride
– Trifluoperazine

These medications have a lower risk of causing postural hypotension compared to other antipsychotics such as risperidone, clozapine, olanzapine, paliperidone, quetiapine, and ziprasidone. It is important to discuss any concerns about side effects with a healthcare provider before making any changes to medication.

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

Flumazenil is not authorized for treating benzodiazepine overdose in the UK, despite its widespread use. It works by competitively inhibiting the benzodiazepine binding site on the GABAA receptor, reversing the effects of benzodiazepines. Due to its short half-life of 60 minutes, it is important to note that multiple doses may be necessary in cases of benzodiazepine overdose.

Flumazenil: A Selective GABAA Receptor Antagonist

Flumazenil is a medication that selectively blocks the effects of benzodiazepines on the GABAA receptor. It is used to reverse the sedative effects caused by benzodiazepines, either partially or completely. Flumazenil works by competitively interacting with benzodiazepine receptors, which can reverse the binding of benzodiazepines to these receptors. It is administered intravenously and has a short half-life of about 60 minutes. The effects of flumazenil are usually shorter than those of benzodiazepines, and sedation may recur. Flumazenil also blocks non-benzodiazepine-agonists like zopiclone. However, it has no effect on other drugs such as barbiturates, ethanol, of other GABA-mimetic agents unless they act on the benzodiazepine receptor site. The hypnosedative effects of benzodiazepines are rapidly blocked within 1-2 minutes after intravenous administration, and the duration of action ranges from 20 to 50 minutes.

While antipsychotics can cause secondary amenorrhoea by increasing prolactin levels, it is important to first rule out pregnancy as it is the most common cause of this condition.

Biogenic Amines: Understanding the Neurotransmitters

Biogenic amines are a class of compounds that are derived from amino acids. These compounds play a crucial role in the functioning of the nervous system. Biogenic amine neurotransmitters include catecholamines (adrenaline, noradrenaline, and dopamine), serotonin, and histamine. A useful mnemonic to remember these neurotransmitters is HANDS (Histamine, Adrenaline, Noradrenaline, Dopamine, Serotonin).

Catecholamines are involved in the body’s response to stress and are responsible for the fight or flight response. Adrenaline and noradrenaline are catecholamines that are released by the adrenal glands in response to stress. Dopamine is involved in the reward system of the brain and is associated with pleasure and motivation.

Serotonin is a neurotransmitter that is involved in mood regulation, appetite, and sleep. It is also involved in the regulation of pain and the perception of pain.

Histamine is involved in the immune response and is responsible for the symptoms of allergies. It is also involved in the regulation of sleep and wakefulness.

Understanding the role of biogenic amines in the nervous system is crucial for the development of treatments for neurological and psychiatric disorders.

ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

Prescribing in the Elderly: Iatrogenic Consequences

Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

Medications Linked to Delirium and Other Cognitive Disorders

Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

Medications Linked to Mood Changes

The following medications are well known to precipitate mood changes:

– Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
– Interferon-a is capable of inducing depressive symptoms.
– Digoxin is capable of inducing depressive symptoms.
– Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
– Antidepressants can precipitate mania.

Medications Linked to Psychosis

The following medications are well known to precipitate psychosis:

– Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
– Corticosteroids

Medications Linked to Anxiety

The following medications are well known to precipitate anxiety:

– Stimulants
– β adrenergic inhalers

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

The biological response to a drug can only be triggered by the portion of the drug that is not bound.

Drug Distribution in the Body

After being absorbed, drugs can distribute to different parts of the body, such as fat, plasma, muscle, brain tissue, and glands like the thyroid. However, for a drug to have an effect, it must be present in the plasma in an unbound state. This means that the drug molecules are not attached to any other molecules and are free to interact with their target receptors. The concentration of unbound drug in the plasma is what determines the drug’s effectiveness and potential side effects. Therefore, understanding a drug’s distribution in the body is crucial for determining the appropriate dosage and monitoring its effects.

Medications that can exacerbate psoriasis symptoms include:
– Lithium
– Selective serotonin reuptake inhibitors (SSRIs)
– Beta blockers
– Angiotensin-converting enzyme (ACE) inhibitors

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

Budesonide is a type of steroid that is often administered through an inhaler to manage asthma symptoms. However, it has been noted that the use of inhaled steroids can trigger episodes of hypomania and mania. This information was reported in a study by E Brown et al. titled The psychiatric side effects of corticosteroids, which was published in the Annals of Allergy, Asthma & Immunology in 1999.

Drug-Induced Mania: Evidence and Precipitating Drugs

There is strong evidence that mania can be triggered by certain drugs, according to Peet (1995). These drugs include levodopa, corticosteroids, anabolic-androgenic steroids, and certain classes of antidepressants such as tricyclic and monoamine oxidase inhibitors.

Additionally, Peet (2012) suggests that there is weaker evidence that mania can be induced by dopaminergic anti-Parkinsonian drugs, thyroxine, iproniazid and isoniazid, sympathomimetic drugs, chloroquine, baclofen, alprazolam, captopril, amphetamine, and phencyclidine.

It is important for healthcare professionals to be aware of the potential for drug-induced mania and to monitor patients closely for any signs of symptoms. Patients should also be informed of the risks associated with these medications and advised to report any unusual changes in mood of behavior.

Stevens-Johnson syndrome, a condition that can be triggered by various anticonvulsants including lamotrigine, appears to align with the patient’s medical history.

Stevens-Johnson syndrome is a severe skin condition that can be caused by medication use of infection. Anticonvulsants, particularly lamotrigine, are often the cause. Symptoms include fever, sore throat, fatigue, and the appearance of ulcers and lesions in the mucous membranes. A rash of round lesions also appears on the face, trunk, arms, legs, and soles of the feet. It is a life-threatening condition that requires immediate medical attention.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

EPSE’s have been linked to the use of fluoxetine, and all of the treatment options are utilized to address them.

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

Serotonin syndrome may sometimes result in increased levels of CPK.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

The liver plays a significant role in breaking down clozapine through the action of CYP450 enzymes, with CYP1A2, CYP3A4, and CYP2D6 being particularly involved in the process.

The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

Agomelatine is a newly developed antidepressant that primarily targets the melatonin receptors, but its antidepressant properties stem from its ability to block serotonin receptors.

Antidepressants (Licensed Indications)

The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.

– Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
– Phobic and obsessional states: Clomipramine
– Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
– Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
– Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
– Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
– OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
– Bulimia nervosa: Fluoxetine
– PTSD: Paroxetine, Sertraline

Elevated levels of creatine phosphokinase (CPK) are observed in NMS.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

Enzyme induction can accelerate drug metabolism and increase the risk of inadequate treatment. This process is often triggered by drugs such as ethanol, rifampin, barbiturates (e.g. phenobarbital, primidone), phenytoin, and carbamazepine. Carbamazepine, for instance, induces its own metabolism through cytochrome P450 enzymes 3A4 and 2E1. Typically, enzyme induction boosts glucuronyl transferase activity, which enhances drug conjugation.

Which two medications have been associated with sudden death and subsequently removed from the UK market due to their effect on the QTc interval?

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

For centuries, individuals from the East coast of Africa have been chewing khat, which produces effects that stem from two phenylalkylamines, cathinone and cathine, both of which are structurally similar to amphetamine. The physical effects of khat include dry mouth, dizziness, impotence, cirrhosis, tachycardia, and tachypnoea.

Valproate can pass through the placenta, increasing the likelihood of birth defects. The extent of risk during pregnancy is not fully understood, but it is believed to be influenced by the dosage. Children who were exposed to valproate in the womb may have a lower IQ, with those aged 6 showing an average decrease of 7-10 points compared to those exposed to other antiepileptic medications.

Valproate: Forms, Doses, and Adverse Effects

Valproate comes in three forms: semi-sodium valproate, valproic acid, and sodium valproate. Semi-sodium valproate is a mix of sodium valproate and valproic acid and is licensed for acute mania associated with bipolar disorder. Valproic acid is also licensed for acute mania, but this is not consistent with the Maudsley Guidelines. Sodium valproate is licensed for epilepsy. It is important to note that doses of sodium valproate and semi-sodium valproate are not the same, with a slightly higher dose required for sodium valproate.

Valproate is associated with many adverse effects, including nausea, tremor, liver injury, vomiting/diarrhea, gingival hyperplasia, memory impairment/confusional state, somnolence, weight gain, anaemia/thrombocytopenia, alopecia (with curly regrowth), severe liver damage, and pancreatitis. Increased liver enzymes are common, particularly at the beginning of therapy, and tend to be transient. Vomiting and diarrhea tend to occur at the start of treatment and remit after a few days. Severe liver damage is most likely to occur in the first six months of therapy, with the maximum risk being between two and twelve weeks. The risk also declines with advancing age.

Valproate is a teratogen and should not be initiated in women of childbearing potential. Approximately 10% of children exposed to valproate monotherapy during pregnancy suffer from congenital malformations, with the risk being dose-dependent. The most common malformations are neural tube defects, facial dysmorphism, cleft lip and palate, craniostenosis, cardiac, renal and urogenital defects, and limb defects. There is also a dose-dependent relationship between valproate and developmental delay, with approximately 30-40% of children exposed in utero experiencing delay in their early development, such as talking and walking later, lower intellectual abilities, poor language skills, and memory problems. There is also a thought to be a 3-fold increase of autism in children exposed in utero.

Benzodiazepines are a class of drugs commonly used to treat anxiety and sleep disorders. It is important to have a working knowledge of the more common benzodiazepines and their half-life. Half-life refers to the amount of time it takes for half of the drug to be eliminated from the body.

Some of the more common benzodiazepines and their half-life include diazepam with a half-life of 20-100 hours, clonazepam with a half-life of 18-50 hours, chlordiazepoxide with a half-life of 5-30 hours, nitrazepam with a half-life of 15-38 hours, temazepam with a half-life of 8-22 hours, lorazepam with a half-life of 10-20 hours, alprazolam with a half-life of 10-15 hours, oxazepam with a half-life of 6-10 hours, zopiclone with a half-life of 5-6 hours, zolpidem with a half-life of 2 hours, and zaleplon with a half-life of 2 hours. Understanding the half-life of these drugs is important for determining dosages and timing of administration.

Diplopia is a frequently occurring side-effect, while the other options are infrequent of extremely infrequent side-effects of carbamazepine.

Carbamazepine: Uses, Mechanism of Action, Contraindications, Warnings, and Side-Effects

Carbamazepine, also known as Tegretol, is a medication commonly used in the treatment of epilepsy, particularly partial seizures. It is also used for neuropathic pain, bipolar disorder, and other conditions. The drug works by binding to sodium channels and increasing their refractory period.

However, carbamazepine has notable contraindications, including a history of bone marrow depression and combination with monoamine oxidase inhibitors (MAOIs). It also carries warnings for serious dermatological reactions such as toxic epidermal necrolysis (TEN) and Stevens Johnson syndrome.

Common side-effects of carbamazepine include leucopenia, ataxia, dizziness, somnolence, vomiting, nausea, urticaria, and fatigue. Other side-effects include thrombocytopenia, eosinophilia, oedema, fluid retention, weight increase, hyponatraemia, and blood osmolarity decreased due to an antidiuretic hormone (ADH)-like effect, leading in rare cases to water intoxication accompanied by lethargy, vomiting, headache, confusional state, neurological disorders, diplopia, accommodation disorders (e.g. blurred vision), and dry mouth.

In summary, carbamazepine is a medication with multiple uses, but it also carries significant contraindications, warnings, and side-effects that should be carefully considered before use.

A drug’s half-life is an estimation of the time it takes for the drug’s initial concentration in the body to decrease by half. For example, if a drug’s half-life is 4 hours and the initial concentration is 160 mg, it’s estimated that 80 mg will remain after 4 hours.

Other important pharmacokinetic values include the volume of distribution, which is the apparent volume that contains the drug, concentration, which is the amount of drug per unit volume, elimination rate constant, which is the rate at which the drug is removed from the body, and clearance, which is the volume of blood cleared of the drug per unit time. When the overall intake of a drug is equal to the rate of elimination, this is known as steady state, which is typically achieved after approximately 4-5 half life times.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

Aripiprazole and olanzapine are preferred over haloperidol due to its high impact on the QTc interval. Risperidone can also be considered as a viable option in cases where the QTc interval is elevated.

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

Antidepressants (Licensed Indications)

The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.

– Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
– Phobic and obsessional states: Clomipramine
– Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
– Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
– Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
– Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
– OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
– Bulimia nervosa: Fluoxetine
– PTSD: Paroxetine, Sertraline

The second generation of H1 antihistamines exhibit limited ability to cross the blood-brain barrier, leading to their non-sedating properties. Furthermore, they possess greater receptor specificity and do not produce significant anticholinergic effects. These characteristics make them a more desirable option for managing allergic conditions, as they minimize the risk of adverse effects.

Antihistamines: Types and Uses

Antihistamines are drugs that block the effects of histamine, a neurotransmitter that regulates physiological function in the gut and potentiates the inflammatory and immune responses of the body. There are two types of antihistamines: H1 receptor blockers and H2 receptor blockers. H1 blockers are mainly used for allergic conditions and sedation, while H2 blockers are used for excess stomach acid.

There are also first and second generation antihistamines. First generation antihistamines, such as diphenhydramine and promethazine, have uses in psychiatry due to their ability to cross the blood brain barrier and their anticholinergic properties. They tend to be sedating and are useful for managing extrapyramidal side effects. Second generation antihistamines, such as loratadine and cetirizine, show limited penetration of the blood brain barrier and are less sedating.

It is important to note that there are contraindications to first-generation antihistamines, including benign prostatic hyperplasia, angle-closure glaucoma, and pyloric stenosis in infants. These do not apply to second-generation antihistamines.

Anticholinergic side effects, such as dry mouth, urinary retention, and dry skin, are commonly associated with Amitriptyline and other tricyclic antidepressants.

Varenicline is a medication that helps people quit smoking by partially activating specific nicotine receptors in the body.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Antipsychotics can be classified in different ways, with the most common being typical (first generation) and atypical (second generation) types. Typical antipsychotics block dopamine (D2) receptors and have varying degrees of M1, Alpha-1, and H1 receptor blockade. Atypical antipsychotics have a lower propensity for extrapyramidal side-effects and are attributed to the combination of relatively lower D2 antagonism with 5HT2A antagonism. They are also classified by structure, with examples including phenothiazines, butyrophenones, thioxanthenes, diphenylbutylpiperidine, dibenzodiazepines, benzoxazoles, thienobenzodiazepine, substituted benzamides, and arylpiperidylindole (quinolone). Studies have found little evidence to support the superiority of atypicals over typicals in terms of efficacy, discontinuation rates, of adherence, with the main difference being the side-effect profile. The Royal College also favors classification by structure.

Antidepressants with Active Metabolites

Many antidepressants have active metabolites that can affect the body’s response to the medication. For example, amitriptyline has nortriptyline as an active metabolite, while clomipramine has desmethyl-clomipramine. Other antidepressants with active metabolites include dosulepin, doxepin, imipramine, lofepramine, fluoxetine, mirtazapine, trazodone, and venlafaxine.

These active metabolites can have different effects on the body compared to the original medication. For example, nortriptyline is a more potent inhibitor of serotonin and norepinephrine reuptake than amitriptyline. Similarly, desipramine, the active metabolite of imipramine and lofepramine, has a longer half-life and is less sedating than the original medication.

It is important for healthcare providers to be aware of the active metabolites of antidepressants when prescribing medication and monitoring patients for side effects and efficacy.

Zotepine, which has been utilized globally to manage schizophrenia, has been removed from the UK market due to its potential to trigger seizures.

Antidepressants (Licensed Indications)

The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.

– Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
– Phobic and obsessional states: Clomipramine
– Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
– Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
– Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
– Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
– OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
– Bulimia nervosa: Fluoxetine
– PTSD: Paroxetine, Sertraline

To avoid potential liver damage, it is recommended to conduct liver function tests (LFTs) before starting agomelatine and periodically at 3, 6, 12, and 24 weeks after beginning treatment. If serum transaminases levels exceed three times the upper normal limit of if symptoms of liver disorder arise, agomelatine treatment should be discontinued.

Antipsychotics and Sexual Dysfunction: Causes, Risks, and Management

Sexual dysfunction is a common side effect of antipsychotic medication, with the highest risk associated with risperidone and haloperidol due to their effect on prolactin levels. Clozapine, olanzapine, quetiapine, aripiprazole, asenapine, and lurasidone are associated with lower rates of sexual dysfunction. The Arizona Sexual Experiences Scale (ASEX) can be used to measure sexual dysfunction before and during treatment. Management options include excluding other causes, watchful waiting, dose reduction, switching to a lower risk agent, adding aripiprazole, considering an antidote medication, of using sildenafil for erectile dysfunction. It is important to address sexual dysfunction to improve quality of life and medication adherence.

Pharmacological management of dementia involves the use of acetylcholinesterase inhibitors (AChE inhibitors) and memantine. AChE inhibitors prevent the breakdown of acetylcholine, which is deficient in Alzheimer’s due to the loss of cholinergic neurons. Donepezil, galantamine, and rivastigmine are commonly used AChE inhibitors in the management of Alzheimer’s. However, gastrointestinal side effects such as nausea and vomiting are common with these drugs.

Memantine, on the other hand, is an NMDA receptor antagonist that blocks the effects of pathologically elevated levels of glutamate that may lead to neuronal dysfunction. It has a half-life of 60-100 hours and is primarily renally eliminated. Common adverse effects of memantine include somnolence, dizziness, hypertension, dyspnea, constipation, headache, and elevated liver function tests.

Overall, pharmacological management of dementia aims to improve cognitive function and slow down the progression of the disease. However, it is important to note that these drugs do not cure dementia and may only provide temporary relief of symptoms.

The given scenario follows first order kinetics, where the elimination rate of a drug depends on its concentration. A 100 mg dose of the drug is administered, with a 10% elimination rate per minute. After 1 minute, 10 mg of the drug is eliminated, leaving 90 mg. After 2 minutes, 9 mg is eliminated, leaving 81 mg. After 3 minutes, 8.1 mg is eliminated, resulting in a total of 27.1 mg eliminated.

Agranulocytosis, a potentially life-threatening condition, is a rare side effect of clozapine occurring in approximately 1% of patients. The period of maximum risk for developing agranulocytosis is between 4-18 weeks after starting treatment. It is important for patients taking clozapine to have regular blood tests and be registered with the Clozaril Patient Monitoring Service to monitor for this side effect. It is worth noting that the risk of agranulocytosis is not related to the dose of clozapine. For more information on the treatment of schizophrenia, the book Contemporary Issues in the Treatment of Schizophrenia edited by Shriqui CL and Nasrallah HA may be of interest.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

Ketamine, typically used in emergency medicine and paediatric anaesthesia, has been found to possess antidepressant properties and is currently being studied for its rapid onset efficacy. However, its acute side effect of inducing dissociation has raised concerns about its suitability for individuals with psychotic symptoms of emotionally unstable personality disorder.

The voltage drop (Vd) is equal to the ratio of the applied voltage (A) to the circuit resistance (C). Therefore, in this case, Vd is equal to 500 volts, as calculated by dividing 50 volts by 0.1 ohms.

Understanding the Volume of Distribution in Pharmacology

The volume of distribution (Vd) is a crucial concept in pharmacology that helps determine how a drug distributes in the body. It is also known as the apparent volume of distribution, as it is an abstract volume. The Vd indicates whether a drug concentrates in the plasma of spreads out in the body. Drugs that are highly polar tend to stay in central compartments such as the plasma, resulting in a low Vd. Conversely, drugs that are more lipid-soluble are distributed widely, such as in fat, resulting in a high Vd.

The Vd is calculated by dividing the amount of drug in the body by the concentration in the plasma. Clinically, the Vd is used to determine the loading dose of a drug required for a desired blood concentration and to estimate blood concentration in the treatment of overdose. The units of Vd are in volume.

The apparent volume of distribution is dependent on the drug’s lipid of water solubility, plasma protein binding, and tissue binding. Plasma protein binding affects the Vd, as drugs that bind to plasma proteins like albumin have a smaller apparent volume of distribution. This is because they are extracted from plasma and included in drug concentration measurements, which can give a misleading impression of their volume of distribution. Understanding the Vd is essential in pharmacology to ensure the safe and effective use of drugs.

Men may experience difficulties with achieving erections and ejaculation when taking medications that inhibit peripheral alpha 1-adrenoceptors. Antipsychotics can lead to disrupted sexual arousal due to their antimuscarinic effects. Impairment of both desire and arousal may occur as a result of dopaminergic blockade and hyperprolactinaemia. Selective serotonin reuptake inhibitor (SSRI) antidepressants, which increase serotonin activity, have been associated with anorgasmia.

Tricyclic antidepressants (TCAs) have side effects that are linked to their anticholinergic, antihistaminergic, and antiadrenergic properties. Even when taken at recommended doses, TCAs can lead to prolonged QT, flattened T wave, depressed ST segment, and tachycardia. Overdosing on TCAs can be fatal and may result in cardiac arrhythmias, which can occur approximately 72-96 hours after the overdose.

CYP1A2 is responsible for metabolizing caffeine, and it competes with other drugs that are also metabolized by this enzyme. When caffeine is consumed excessively, it can deplete the CYP1A2, leaving none available to metabolize clozapine, resulting in increased levels of clozapine. However, this is not a common issue in clinical settings.

The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Suboxone vs. Subutex: What’s the Difference?

Suboxone and Subutex are both medications used to treat opioid addiction. However, there are some key differences between the two.

Suboxone is a combination of buprenorphine and naloxone. The naloxone is added to prevent people from injecting the medication, as this was a common problem with pure buprenorphine tablets. If someone tries to inject Suboxone, the naloxone will cause intense withdrawal symptoms. However, if the tablet is swallowed as directed, the naloxone is not absorbed by the gut and does not cause any problems.

Subutex, on the other hand, contains only buprenorphine and does not include naloxone. This means that it may be more likely to be abused by injection, as there is no deterrent to prevent people from doing so.

Overall, both Suboxone and Subutex can be effective treatments for opioid addiction, but Suboxone may be a safer choice due to the addition of naloxone.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

The First Pass Effect in Psychiatric Drugs

The first-pass effect is a process in drug metabolism that significantly reduces the concentration of a drug before it reaches the systemic circulation. This phenomenon is related to the liver and gut wall, which absorb and metabolize the drug before it can enter the bloodstream. Psychiatric drugs are not exempt from this effect, and some undergo a significant reduction in concentration before reaching their target site. Examples of psychiatric drugs that undergo a significant first-pass effect include imipramine, fluphenazine, morphine, diazepam, and buprenorphine. On the other hand, some drugs undergo little to no first-pass effect, such as lithium and pregabalin.

Orally administered drugs are the most affected by the first-pass effect. However, there are other routes of administration that can avoid of partly avoid this effect. These include sublingual, rectal (partly avoids first pass), intravenous, intramuscular, transdermal, and inhalation. Understanding the first-pass effect is crucial in drug development and administration, especially in psychiatric drugs, where the concentration of the drug can significantly affect its efficacy and safety.

In contrast to first order reactions, drugs that exhibit zero order kinetics do not have a fixed half-life, as the rate of drug elimination remains constant regardless of the drug concentration in the plasma. The relationship between time and plasma concentration in zero order kinetics is linear, whereas in first order reactions, the half-life remains constant.

The half-life of a drug is the time taken for its concentration to fall to one half of its value. Drugs with long half-lives may require a loading dose to achieve therapeutic plasma concentrations rapidly. It takes about 4.5 half-lives to reach steady state plasma levels. Most drugs follow first order kinetics, where a constant fraction of the drug in the body is eliminated per unit time. However, some drugs may follow zero order kinetics, where the plasma concentration of the drug decreases at a constant rate, despite the concentration of the drug. For drugs with nonlinear kinetics of dose-dependent kinetics, the relationship between the AUC of CSS and dose is not linear, and the kinetic parameters may vary depending on the administered dose.

Without prior knowledge, it would be difficult to accurately answer this question. However, one could make an educated guess by eliminating the options of 5, 9, and: and narrowing down the possible answers.

Pharmacological management of dementia involves the use of acetylcholinesterase inhibitors (AChE inhibitors) and memantine. AChE inhibitors prevent the breakdown of acetylcholine, which is deficient in Alzheimer’s due to the loss of cholinergic neurons. Donepezil, galantamine, and rivastigmine are commonly used AChE inhibitors in the management of Alzheimer’s. However, gastrointestinal side effects such as nausea and vomiting are common with these drugs.

Memantine, on the other hand, is an NMDA receptor antagonist that blocks the effects of pathologically elevated levels of glutamate that may lead to neuronal dysfunction. It has a half-life of 60-100 hours and is primarily renally eliminated. Common adverse effects of memantine include somnolence, dizziness, hypertension, dyspnea, constipation, headache, and elevated liver function tests.

Overall, pharmacological management of dementia aims to improve cognitive function and slow down the progression of the disease. However, it is important to note that these drugs do not cure dementia and may only provide temporary relief of symptoms.

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