Psychiatric & Endocrine

Anti-depressants

SSRIs

Uses: Depression, panic disorder, anxiety
Dose: Escitalopram 10-20mg once daily
Adverse Effects: GI (e.g. nausea, vomiting), Antimuscarinic (fewer than TCAs), cardiotoxic in overdose (less than TCA)
Contraindications: Not if < 18y (except fluoxetine).

TCAs

Uses: Moderate-severe depression associated with psychomotor/physiological changes (e.g. sleep/apetite disturbance), nocturnal enuresis in children. E.g. Imipramine
Adverse Effects: Cardiac (arryhythmiax, heart block), antimuscarinic (dy mouth, blurred vision, constipation, urinary retention), overdose

Benzodiazepines

Uses: Hypnotic, short term relief of severe anxiety, panic disorders. Longer acting e.g. diazepam, shorter acting e.g. lorazepam.
Dose: Mouth: 2mg tds
Adverse Effects: Dependence, drowsiness, confusion, ataxia, amnesia, muscle weakness
Contraindications: Resp depression, sleep apnoea, sev hepatic impairment

Insulin

Ultra-fast (use w meals): Humalog, novarapid
Soluble (30m before meals): Humilin S, Actrapid
Intermediate acting: Humilin I or Insulatard
Long acting: Ultratard
Long acting analogue: Lanctus/inslin glargine
Premixed: Novomix 30

Oral Hypoglycaemics

If overweight start with metformin (side effect: slimming), if underweight start with sulfonylurea (side effect: weight gain).

Biguanides: metformin (the only one!)

Mechanism: ↑Insulin sensitivity (also a treatment for PCOS)
Adverse effects: GI (anorexia, nausea...), lactic acidosis
Contraindicaitons: liver/renal impairment (lactic acidosis), recent MI, XR contrast, general anaesthesia, pregnancy, breast feeding

Sulfonylureas

Example: tolbutamide
Mechanism: ↑Insulin secretion.
Adverse Effects: GI, liver function (→cholestasis).
Contraindications: Liver/renal impirment, breast-feeding, pregnancy, ketoacidosis

Thiazolidinediones

Example: rosiglitazone
Mechanism: ↑Insulin sensitivity

Contraception

Starting the pill:

1. Be empathic
2. Enquire: Sexually active, partner, consenting relationship (if underaged), last period (?risk of pregnancy), smoking
3. Options, failures, SEs, how to take pill reliably, what to do if miss pill, extra protection w abx. “Do u have any questions or concerns”, arrange follow up

Missing the pill:

• CoC: If <12h late protection maintained. If >12h take as soon as possible but use barrier for 7d (if that 7d runs in to pill-free, than continue next packet w/o break). Vomiting within 2h of taking pill: advice for missed pills
• PoC: Take as soon as possible and resume normal schedule. If >3h late use backup.
  

Emergency Contraception:

• Progesterone only: Levorgestrel 1.5mg as soon as possible
• IUD: Cu coil up to 5d after

Methods of Contraception

Combined Oral Contraceptive (CoC)

Mechanism: (E and P): prevent ovulation, thicken cervical mucus, dec receptivity.
Advantages: Effective, reversible, convenient, relief of menstrual probs/less ovarian/endometrial Ca, protect against PID.
Disadvantages: Headaches, ↑BP, breakthrough bleeding, weight gain, breast tenderness, acne, mood swings, no protection for STDs.
Risks: TED, MI/stroke, br Ca, cervical Ca, liver Ca.
Contraindications:

• CVS: hx or FH of thrombosis, clotting disorders, IHD, valvular hrt disease, AF, sickle cell anaemia
• Migraine w aura or sev migraine
• Hepatic: abn LFTs, jaundice of pregnancy
• Other: hormone dependent carcinoma, pregnancy, undiagnosed vaginal bleeding

Relative Contraindications: DM, ↑BP, smoking, age>35, obesity
Interactions: ↑dose if broad spectrum abx, enzyme inducers (eg. carbamezepine, phenytoin, rifampicin).

Progesterone Only Pill (PoP)

Examples: norethisterone, levonorgestrel
Advantages: Reliable, reversible, convenient, avoid CVS effects of estrogen, used if contraindication to CoC, can use during breast feeding.
Disadvantages: Amenorrhoea/breakthrough bleeding, needs to be taken same time daily, including ovarian cysts and possible br Ca.

Injectables

Examples: Depo-Provera
Mechanism: long acting progesterone prevents ovulation, thicken mucus, decreases uterine receptivity.
Advantages: Effective, convenient, br feeding. ⊖Cannot be stopped, menstrual irregularities common, wt gain common.

Subdermal implant

Example: Implanon
Mechanism: A progesterone rod Similar to injectables, but long duration. ⊖Similar to injectables.

IUD

Mechanism: Cu wire. Left in 5y years. Induces inflammatory response in uterus.
Advantages: Effective (immediately after fitting), reversible, convenient.
Disadvantages: Bleeding between periods, menorrhagia first few cycles, uterine perforation (first 20d, ectopic pregnancy (if failure, so low absolute risk).

Levonorgestrel IUD

Example: Mirena
Mechanism: T shaped, 5y, reduces endometrial growth and prevents implantation.
Advantages: Effective, convenient, reversible, reduces blood loss and dysmenorrhoea.
Disadvantages: Menstrual irreg for first m's, prestegenic SEs, ovarian cyst.

Diaphragms/Caps

Advantages: Insertion before intercouse allows spontaneity, protect against STIs.
Disadvantages: Less convenient.

Condoms

Advantages: Protects against STDs.
Disadvantages: Planning, lacks spontaneity, cooperation from both partners, can fail.

Natural

Advantages: No SEs.
Disadvantages: Commitment, unreliable.