What is the 1st line management of Delirium Tremens?
Oral Lorazepam
N.B. Haloperidol use is reserved for those who do not respond to oral lorazepam
Thiamine should be started but is not the most important initial treatment
What is the management of alcohol withdrawal?
1st Line) Benzodiazepines → e.g. chlordiazepoxide
- typically given as part of a reducing dose protocol
2nd) Carbamazepine also effective in treatment of alcohol withdrawal
N.B. Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
What is the step-wise approach to the management of Generalised Anxiety Disorder (GAD)?
Step 1 ) education about GAD and active monitoring
Step 2 ) low intensity psychological interventions
- individual non-facilitated self-help
- individual guided self-help
- psychoeducational groups
Step 3 ) high intensity psychological interventions
- CBT
- applied relaxation
- drug treatment
Step 4 ) highly specialist input → e.g. multi-agency teams
Drug Treatment
- NICE suggest Sertraline should be considered the 1st line SSRI
- Interestingly for patients < 30 years NICE recommend you warn patients of the increased ↑ risk of suicidal thinking and self-harm
- Weekly follow-up is recommended for the 1st month
What is the step-wise approach to the management of Panic Disorder?
1) Recognition and Diagnosis
2) Treatment in PRIMARY CARE →
- NICE → CBT or medication
- SSRIs are 1st line
- if contraindicated/no response after 12 weeks ⟶ IMIPRAMINE (TCAs) or CLOMIPRAMINE should be offered
3) Review and consideration of alternative treatments
4) Review and referral to specialist mental health services
5) Care in specialist mental health services
Which SSRIs should be prescribed in depression?
- Citalopram and Fluoxetine are currently the preferred SSRIs
- Sertraline is useful post-MI → as there is more evidence for its safe use in this situation than other antidepressants
- SSRIs should be used with caution in children and adolescents → Fluoxetine is the drug of choice when an antidepressant is indicated
What are the potential adverse effects or SSRIs?
- GI symptoms are the most common side-effect
- ↑ risk of GI bleeding in patients taking SSRIs
- PPI (proton pump inhibitor) should be prescribed IF a patient is also taking a NSAID
- Patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
- Drug Interactions → fluoxetine and paroxetine have a higher propensity
What is a precaution should be taken when prescribing citalopram?
QT INTERVAL PROLONGATION
- advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation
- should not be used in those with →
- congenital long QT syndrome
- known pre-existing QT interval prolongation
- in combination with other medicines that prolong the QT interval
- the maximum daily dose →
- 40 mg for adults
- 20 mg for patients > 65 years
- 20 mg for those with hepatic impairment
What are the drug interactions seen with SSRIs?
- NSAIDs → NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
- Warfarin/Heparin → NICE guidelines recommend avoiding SSRIs and considering mirtazapine (noradrenergic and specific serotonergic antidepressant - NaSSA)
- Aspirin → see above
- Triptans → avoid SSRIs
How should SSRIs be monitored?
- Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks
- For patients under the < 30 years old OR at ↑ risk of suicide they should be reviewed after 1 week
- If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months AFTER remission as this ↓ risk of relapse
How should SSRIs be discontinued and what are some of the commonly seen symptoms?
When stopping a SSRI the dose should be ↓ gradually reduced over a 4 week period
N.B. this is not necessary with fluoxetine
Paroxetine has a ↑ incidence of discontinuation symptoms
_Discontinuation Symptoms_
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- GI symptoms → pain, cramping, diarrhoea, vomiting
- paraesthesia
What adviceb should be given with regards to SSRIs in pregnancy?
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy
- Use during the 1st trimester gives a small ↑ risk of congenital heart defects
- Use during the 3rd trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine → has an ↑ risk of congenital malformations
- particularly in the 1st trimester
How should benzodiazepine withdrawal be managed?
The dose should be withdrawn in steps of about 1/8 of the daily dose every fortnight
A suggested protocol for patients experiencing difficulty is given →
- switch patients to the equivalent dose of diazepam
- ↓ dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
- time needed for withdrawal can vary from 4 weeks - year or more
What is the management of PTSD?
- following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
- watchful waiting may be used for mild symptoms lasting < 4 weeks
- military personnel have access to treatment provided by the armed forces
- trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
- drug treatments for PTSD should not be used as a routine first-line treatment for adults
- if drug treatment is used then paroxetine or mirtazapine are recommended
What is the management of neuroleptic malignant syndrome?
IV fluid rehydration, dantrolene (an antagonist of the ryanodine receptor) and bromocriptine (a dopamine agonist that acts centrally)
