BNF - Chapter 4 - Nervous System - (Part 1) Flashcards
What is Dementia?
It is a progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms that can include memory loss, problems with reasoning and communication, a change in personality, and a reduced ability to carry out daily activities such as washing or dressing.
What is the most common type of dementia?
Alzheimer’s disease
What are some of the other common types of dementia?
- vascular dementia (due to cerebrovascular disease)
- dementia with Lewy bodies
- Mixed dementia
- Frontotemporal dementia
What are some commonly prescribed drugs associated with?
- increased antimuscarinic (anticholinergic) burden and therefore cognitive impariment
- their use should be minimised
Which drugs have antimuscarinic effects? give few examples?
some antidepressants (e.g. amitriptyline hydrochloride, paroxetine), antihistamines (e.g. chlorphenamine maleate, promethazine hydrochloride), antipsychotics (e.g. olanzapine, quetiapine), and urinary antispasmodics (e.g. solifenacin succinate, tolterodine tartrate)
For patients with mild-moderate Alzheirmer’s disease what is first line treatment?
monotherapy with:
- donepezil
- galantamine
- rivastigmine
(They are all acetylcholinesterase inhibitors)
If Cholinesterase inhibiotrs is not suitable or (not well tolerated) or contraindicated then what may be given?
Memantine - (suitable alternative for moderate AD)
What is the drug of choice for severe AD?
- Memantine
What if patients are already on a acetylcholinesterase inhibitors and their AD gets worse to moderate or severe disease?
- Add memantine to the acetylcholinesterase inhibitor.
- For this memantine can be initiated in primary care without advice from specialist clinician.
In patients with moderate AD, what effect can discontinuing acetylcholinesterase have?
Substantial worsening in cognitive function; treatment discontinuation should not be based on disease severity alone
Can acetylcholinesterase inhibitors or memantine be used in patients with frontotemporal dementia?
not recommended in patients with frontotemporal dementia or cognitive impairment caused by multiple sclerosis
What can be given in dementia patients for management of non-cognitive symptoms (agitation, aggression, distress and psychosis)?
- Antipsychotic drugs should only be offered to patients with dementia if they are either at risk of harming themselves or others. or experience agitation, hallucinations or delusions that are causing them severe distress.
What warning has MHRA issued regarding antipsychotic use in elderly patients with dementia?
- Increased risk of stroke and a small increased risk of death
How regularly should the antipsychotics be reviewed?
Antipsychotic drugs should be used at the lowest effective dose and for the shortest time possible, with a regular review at least every 6 weeks.
In patients who have dementia with Lewy bodies or Parkinson’s disease dementia - what effect can antipsychotics use have?
They can worsen the motor features of the condition and in some cases cause severe antipsychotic sensitivity reactions
Name three acetylcholinesterase inhibitors that can be used in dementia AD?
- Donepezil
- Galantamine
- Rivastigmine
What class of drug does memantine belong to?
NMDA receptor antagonist
What is the direction for administration of donepezil oridispersible tablets?
- should be placed on the tongue, allowed to disperse, and swallowed.
What is the MAO of donepezil?
It is a reversible inhibitor of acetylcholinesterase
What is the MAO of galantamine?
- it is a reversible inhibitor of acetylcholinesterase and it also has nicotinic receptor agonist properties.
Does skin reactions when on galantamine prompt patient to seek GP help?
Yes - They should be advised to stop taking galantamine immediately and seek medical advice if symptoms occur.
What is the MAO of rivastigmine?
It is a reversible non-competitive inhibitor of acetylcholinesterase.
What is the MAO of memantine?
It is a glutamate receptor antagonist (NMDA receptor antagonist)
What is epilepsy?
Epilepsy is a common condition where sudden bursts of electrical activity in the brain cause seizures or fits.
What is the aim of treatment of epilepsy?
- To prevent the occurrence of seizures by maintaining an effective dose of one or more antiepileptic drugs
Before choosing an antiepileptic drug what regarding the epilepsy should be considered?
- When choosing an antiepileptic drug, the presenting epilepsy syndrome should first be considered. If the syndrome is not clear, the seizure type should determine the choice of treatment. Concomitant medication, co-morbidity, age, and sex should also be taken into account.
Which anti-epileptic drugs have a long half life which can usually be given once daily at bedtime?
- Lamotrigine
- Perampanel
- phenobarbital
- Phenytoin
However, with large doses, some antiepileptics may need to be given more frequently to avoid adverse effects associated with high peak plasma-drug concentration.
Is monotherapy recommended with management of epilepsy?
- Monotherapy with an anti-epileptic drug should be tried first
- When this has failed mono-therapy with a second drug should be tried
- Combination therapy with two or more anti-epileptic drugs may be necessary, but the concurrent use of antiepileptic drugs increases the risk of adverse effects and drug interactions.
- Wherever possible, a single antiepileptic drug should be prescribed
What MHRA warning was issued by antiepileptic drugs?
- all antiepileptic drugs may be associated with a small increased risk of suicidal thoughts and behaviour; symptoms may occur as early as 1 week after starting treatment
Antiepileptic drugs have been divided in to how many risk-based categories to help healthcare professionals decide whether it is necessary to maintain continuity of supply of a specific manufacturer’s product
3 categories
Category 1
Category 2
Category 3
What is category 1 anti-epileptics and which drugs are in this catgeory?
- Carbamazepine
- Phenobarbital
- Phenytoin
- Primidone
For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product.
What is category 2 antiepileptics and which drugs are in this category?
- Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide.
For these drugs, the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with the patient and/or carer taking into account factors such as seizure frequency, treatment history, and potential implications to the patient of having a breakthrough seizure. Non-clinical factors as for Category 3 drugs should also be considered.
What is category 3 antiepileptics and which drugs are in this category?
Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin
For these drugs, it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed, however, other factors are important when considering whether switching is appropriate. Differences between alternative products (e.g. product name, packaging, appearance, and taste) may be perceived negatively by patients and/or carers, and may lead to dissatisfaction, anxiety, confusion, dosing errors, and reduced adherence. In addition, difficulties for patients with co-morbid autism, mental health problems, or learning disability should also be considered.
Which antiepileptic drugs can be associated with rare antiepileptic hypersensitivity syndrome?
carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide
Some other antiepileptics (eslicarbazepine, stiripentol, and zonisamide) have a theoretical risk.
What are the symptoms of antiepileptic hypersensitivity syndrome?
he symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy are most commonly seen. Other systemic signs include liver dysfunction, haematological, renal, and pulmonary abnormalities, vasculitis, and multi-organ failure. If signs or symptoms of hypersensitivity syndrome occur, the drug should be withdrawn immediately, the patient must not be re-exposed, and expert advice should be sought.
In a patient receiving several antiepileptic drugs how should withdrawal occur?
- only one drug should withdrawn at a time
If a driver has a seizure (of any type) who must they inform immediately?
DVLA
How long must patients not drive who have had a first unprovoked epileptic seizure or a single isolated seizure?
Must not drive for 6 months, driving may then be resumed, provided the patient has been assessed by a specialist as fit to drive and investigations do not suggest a risk of further seizures
Can patients with establish epilepsy drive?
Patients with established epilepsy may drive a motor vehicle provided they are not a danger to the public and are compliant with treatment and follow up.
what are the conditions in which will allow a person with established epilepsy to still drive?
To continue driving, these patients must be seizure-free for at least one year (or have a pattern of seizures established for one year where there is no influence on their level of consciousness or the ability to act); also, they must not have a history of unprovoked seizures.
Are there any additional criteria which apply for drivers of large goods or passenger carrying vehicles?
Yes there is additional criteria (more strict - consult DVLA)
Are patients who have had a seizure while asleep permitted to drive?
Patients who have had a seizure while asleep are not permitted to drive for one year from the date of each seizure, unless:
a history or pattern of sleep seizures occurring only ever while asleep has been established over the course of at least one year from the date of the first sleep seizure; or
an established pattern of purely asleep seizures can be demonstrated over the course of three years if the patient has previously had seizures whilst awake (or awake and asleep)
What does DVLA recommend regarding epileptic patients driving who are undergoing medication changes or withdrawing treatment?
The DVLA recommends that patients should not drive during medication changes or withdrawal of antiepileptic drugs, and for 6 months after their last dose.
If a seizure occurs due to a prescribed change or withdrawal of epilepsy treatment, what will happen to the patient’s license?
It will be revoked for 1 year;
relicensing may be considered earlier if treatment has been reinstated for 6 months and no further seizures have occurred
What are the teratogenic effects of valproate?
Valproate, in particular, is highly teratogenic and evidence supports that use in pregnancy leads to congenital malformations (approximately 10% risk) and neurodevelopmental disorders (approximately 30–40% risk).
Is PPP required for valproate?
Prescribers are reminded that valproate must not be used in females of childbearing potential unless the conditions of the Pregnancy Prevention Programme are met and alternative treatments are ineffective or not tolerated.
Valproate must not be used during pregnancy unless there is no other suitable alternative.
If epileptic drugs have to be used during pregnancy, studies have shown which two drugs are preferred to be used in pregnancy?
- Lamotrigine and levetiracetam
large studies of pregnancies exposed to lamotrigine or levetiracetam monotherapy did not suggest an increased risk of major congenital malformations (at usual maintenance doses).
however the data were inadequate to completely rule out the possibility of an increased risk.
To reduce the risk of neural tube defects, what supplementation is advised throughout the first trimester?
- Folate supplementation
folic acid 5mg
Female patients who have seizures in the second half of pregnancy should be assessed for what before any changes is made to antiepileptic treatment?
- Should be assess for eclampsia
What does routine injection of vitamin K at birth minimise the risk of that is associated with antiepileptics?
Neonatal haemorrhage
All pregnant females with epilepsy, whether taking medication or not should be encouraged to notify who?
the UK Epilepsy and Pregnancy Register
Should women taking antiepileptic monotherapy generally be encouraged to breast-feed?
Yes
What should all infants whose mother took antiepileptic drugs be monitored for?
All infants should be monitored for sedation, feeding difficulties, adequate weight gain, and developmental milestones. Infants should also be monitored for adverse effects associated with the antiepileptic drug particularly with newer antiepileptics, if the antiepileptic is readily transferred into breast-milk causing high infant serum-drug concentrations (e.g. ethosuximide, lamotrigine, primidone, and zonisamide), or if slower metabolism in the infant causes drugs to accumulate (e.g. phenobarbital and lamotrigine).
Which anti-epileptics are associated with an established risk of drowsiness in breast-fed babies and in which caution is required?
Primidone, phenobarbital, and the benzodiazepines
Withdrawal effects may occur in infants if a mother suddenly stops breastfeeding, particularly with which drugs?
- Phenobarbital
- Primidone
- Lamotrigine
What is the drug treatment for focal seizures with or without secondary generalisation?
For focal seizures:
1st Line = carbamazepine or lamotrigine
(oxcarbazepine, sodium valproate and levetiracetam may be used if carbamazepine or lamotrigine are unsuitable or not tolerated)
- If monotherapy is unsuccessful with two of these first-line antiepileptic drugs, adjunctive treatment may be considered.
Options for adjunctive treatment include carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate, or topiramate.
If adjunctive treatment is ineffective or not tolerated, a tertiary epilepsy specialist should be consulted who may consider eslicarbazepine acetate, lacosamide, phenobarbital, phenytoin, pregabalin, tiagabine, vigabatrin and zonisamide.
What are the meanings of different types of seizures?
Focal = localised to one hemisphere of the brain
Tonic-clonic = Tonic (body is rigid), Clonic (uncontrolled jerking)
Myoclonic = shock-like jerks of muscles,
Absence = spells of STARING.
What is the treatment steps for Tonic-clonic seizures?
1st line = sodium valproate (except in female patients who are premenopausal)
Lamotrigine is the alternative, but may exacerbate myoclonic seizures.
What is the treatment steps for myoclonic seizures?
1st line = sodium valproate (excpet for in female patients who are premenopausal).
2nd = topiramate and levetiracetam are alternative options
Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine and vigabatrin are not recommended for the treatment of myoclonic seizure
What is the treatment steps for absence seizures?
- Ethosuximide or sodium valproate (except in female patients who are premenopausal)
lamotrigine is a suitable alternative when ethosuximide and sodium valproate are unsuitable, ineffective or not tolerated
Sodium valproate should be used as the first choice if there is a high risk of generalised tonic-clonic seizures.
Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine and vigabatrin are not recommended in absence seizures or syndromes
Atonic and tonic seizures are usually seen in what ages?
Usually seen in childhood, in specific epilepsy syndromes or associated with cerebral damage or mental retardation
What is the treatment for atonic and tonic seizures?
They may respond poorly to the traditional drugs. Sodium valproate is the drug of choice (except in female patients who are premenopausal, see Valproate below); lamotrigine can be added as adjunctive treatment. If adjunctive treatment is ineffective or not tolerated, a tertiary epilepsy specialist should be consulted, and may consider rufinamide or topiramate.
Carbamazepine, gabapentin, oxcarbazepine, pregabalin, tiagabine or vigabatrin are not recommended in atonic and tonic seizures.
What is the first line treatment of Dravet syndrome and Lennox-Gastaut syndrome?
- Sodium valproate
To summaries what is the first line options for focal seizures?
Carbamazepine or lamotrigine
To summaries what is the first line options for tonic clonic and myoclonic seizures?
Sodium Valproate
To summaries what is the first line options for absence seizures?
Ethosuximide
Sodium valproate
Carbamazepine may exacerbate which types of seizures and should be avoided if these are present?
Carbamazepine may exacerbate tonic, atonic, myoclonic and absence seizures and is therefore not recommended if these seizures are present.
What types of seizures is oxcarbazepine licensed as monotherapy or adjunct therapy for?
for the treatment of focal seizures with or without secondary generalised tonic-clonic seizures.
Oxcarbazepine is not recommended in tonic, atonic, absence or myoclonic seizures due to the risk of seizure exacerbation
Which seizure type is ethosuximide licensed to be used for?
- First line treatment option for absence seizures
- It may also be prescribed as adjunctive treatment for absence seizures when monotherapy is ineffective
Ethosuximide is also licensed for myoclonic seizures.
What seizure types are gabapentin or pregabalin licensed for?
- Gabapentin and pregabalin are used for the treatment of focal seizures with or without secondary generalisation.
- They are not recommended if tonic, atonic, absence or myoclonic seizures are present. Both are also licensed for the treatment of neuropathic pain. Pregabalin is licensed for the treatment of generalised anxiety disorder.
What is Lamotrigine used for?
Lamotrigine is an antiepileptic drug recommended as a first-line treatment for focal seizures and primary and secondary generalised tonic-clonic seizures.
Myoclonic seizures may be exacerbated by lamotrigine and it can cause serious rashes especially in children; dose recommendations should be adhered to closely.
What is the effects of other antiepileptics on lamtrogine?
Valproate increases plasma-lamotrigine concentration, whereas the enzyme-inducing antiepileptics reduce it; care is therefore required in choosing the appropriate initial dose and subsequent titration
What are the uses of levetiracetam?
is used for monotherapy and adjunctive treatment of focal seizures with or without secondary generalisation, and for adjunctive treatment of myoclonic seizures in patients with juvenile myoclonic epilepsy and primary generalised tonic-clonic seizures.
What is the use of brivaracetam?
Brivaracetam is used as adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalisation.
What is the use of phenobarbital in epilepsy?
Phenobarbital is effective for tonic-clonic and focal seizures but may be sedative in adults. It may be tried for atypical absence, atonic, and tonic seizures. Rebound seizures may be a problem on withdrawal.
What is primidone converted to?
Largely converted to phenobarbital and this is probably responsible for its antiepileptic action
A low initial dose of primidone is essential
What is the use of phenytoin in seizures?
Phenytoin is licensed for tonic-clonic and focal seizures but may exacerbate absence or myoclonic seizures and should be avoided if these seizures are present. It has a narrow therapeutic index and the relationship between dose and plasma-drug concentration is non-linear; small dosage increases in some patients may produce large increases in plasma concentration with acute toxic side-effects
Similarly, a few missed doses or a small change in drug absorption may result in a marked change in plasma-drug concentration. Monitoring of plasma-drug concentration improves dosage adjustment.
Which treatment of seizures is rufinamide licensed in?
Rufinamide is licensed for the adjunctive treatment of seizures in Lennox-Gastaut syndrome
What type of seizure is zonisamide licensed for?
Zonisamide can be used alone for the treatment of focal seizures with or without secondary generalisation in adults with newly diagnosed epilepsy, and as adjunctive treatment for refractory focal seizures with or without secondary generalisation in adults and children aged 6 years and above
Which benzodiazepine is used in epilepsy control (management)?
- Clobazam
- Clonazepam
What is the drug Acetazolamide and what role does this drug play in treating epilepsy?
Acetazolamide, a carbonic anhydrase inhibitor, has a specific role in treating epilepsy associated with menstruation.
What is status epilepticus?
A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death
What is the immediate measures required to manage status epilepticus?
- positioning the patient to avoid injury
- supporting respiration including the provision of oxygen
- Maintaining blood pressure
- correction of any hypoglycaemia
Parenteral thiamine should be considered in which patients?
If alcohol abuse is suspected
When should pyridoxine hydrochloride be given?
pyridoxine hydrochloride should be given if the status epilepticus is caused by pyridoxine hydrochloride deficiency.
What should seizures lasting longer than 5 minutes be treated with?
With intravenous lorazepam (repeated once after 10 minutes if seizures recur or fail to respond).
Why is IV diazepam not used?
Intravenous diazepam is effective but it carries a high risk of thrombophlebitis (reduced by using an emulsion formulation). Absorption of diazepam from intramuscular injection or from suppositories is too slow for treatment of status epilepticus.
during status epilepticus what should patients be monitored for?
respiratory depression and hypotension
For status epilepticus, Where facilities for resuscitation are not immediately available what can be adminsitered?
diazepam can be administered as a rectal solution or midazolam oromucosal solution can be given into the buccal cavity.
If after initial treatment with benzodiazepines, seizures recur or fail to respond 25 minutes after onset, what should be used?
phenytoin sodium, fosphenytoin sodium, or phenobarbital sodium should be used; contact intensive care unit if seizures continue. If these measures fail to control seizures 45 minutes after onset, anaesthesia with thiopental sodium, midazolam, or a non-barbiturate anaesthetic such as propofol [unlicensed indication], should be instituted with full intensive care support.
How should phenytoin be given for status epilepticus?
By slow intravenous injection, followed by the maintenance dosage if appropriate
Alternatively, fosphenytoin sodium (a pro-drug of phenytoin), can be given more rapidly and when given intravenously causes fewer injection-site reactions than phenytoin sodium.
Although it can also be given intramuscularly, absorption is too slow by this route for treatment of status epilepticus
What should doses of fosphenytoin be expressed as?
in terms of phenytoin sodium
What is the treatment for non-convulsive status epilepticus?
If there is incomplete loss of awareness, usual oral antiepileptic therapy should be continued or restarted.
Patients who fail to respond to oral antiepileptic therapy or have complete lack of awareness can be treated in the same way as for convulsive status epilepticus, although anaesthesia is rarely needed
What is febrile convulsions?
Febrile seizures (febrile convulsions) are fits that can happen when a child has a fever. They most often happen between the ages of 6 months and 3 years.
What is the treatment for febrile convulsions?
- Brief febrile convulsions need no specific treatment; antipyretic medication (e.g. paracetamol), is commonly used to reduce fever and prevent further convulsions but evidence to support this practice is lacking.
Prolonged febrile convulsions (those lasting 5 minutes or longer), or recurrent febrile convulsions without recovery must be treated actively (as for convulsive status epilepticus).
Is long-term anticonvulsant prophylaxis indicated for febrile conulsions?
No it is rarely indicated
Which seizures is cannabidiol licensed to be used in?
- seizures associated with Lennox-Gastaut syndrome (adjnct treatment with clobazam)
- Seizures associated with Dravet syndrome (adjunct treatment with clobazam)
Manufacturer advices if how many doses are missed of cannabidiol will require re-titration?
7 doses
Why is clobazam prescriptions often have endorsement ‘SLS’?
Clobazam is not prescriable in NHS primary care except for the treatment of epilepsy, endorse prescription ‘SLS’
Can clonazepam be used for all forms of epilepsy?
Yes
For treatment of status epilepticus, when no improvement after IV lorazepam then no improvement with phenytoin, which anaesthesia is used?
Thiopental sodium
What is the dose and route of lorazepam for treatment of status epilepticus?
Slow intravenous infusion
- 4mg for 1 dose, then 4mg after 10 minutes if required for 1 dose, to be administered into a large vein
What is anxiety?
It is a general term for several disorders that cause nervousness, fear and worrying
Can benzodiazepines be used for anxiety?
Yes they are indicated but for short term relief of anxiety that is causing unacceptable distress (for 2-4 weeks only).
e.g. diazepam
Lowest possible dose for shortest period of time
What are the symptoms of benzodiazepine overdose?
- drowsiness
- Ataxia
- Dysarthria
- Coma
What can high doses of benzodiazepines being administered during late pregnancy or labour cause?
- may cause neonatal hypothermia, hypotonia and respiratory depression
What are beta blockers useful for in anxiety?
- they reduce palpitations and tremors which can prevent onset of worry + fear
What is classed as chronic anxiety?
Lasting more than 4 weeks.
For chronic anxiety what drug class may be appropriate to use?
- An antidepressant
What should patients with generalised anxiety disorder (a form of chronic anxiety) be offered?
- Psychological treatment followed by an SSR (E.g. Escitalopram)
- Duloxetine and venlafaxine (Serotonin and noradrenaline re-uptake inhibitors) can also be used.
- If a patient cannot tolerate the above/ treatment is ineffective, then pregabalin can be considered
What class of drug does buspirone belong to?
Antidepressant - serotonin receptor agonists
What is the indications of buspirone?
Anxiety (short-term use)
Can buspirone be used for epileptic patient?
No it is CI in epilepsy
Which benzodiazepines can be used for anxiety?
Alprazolam
Chlordiazepoxide hydrochloride
Diazepam
Oxazepam
What is ADHA?
Attention deficit hyperactivity disorder (ADHA) is a behavioural disorder characterised by hyperactivity, impulsivity and inattention, which can lead to functional impairment such as psychological, social, educational or occupation difficulties.
Which age range does symptoms of ADHA typically appear?
3-7 years, but may not be recognised until after 7 years of age, especially if hyperactivity is not present.
Is ADHD more commonly diagnosed in males or females?
more commonly diagnosed in males
Which other conditions is associated with ADHD which there is an increased risk of?
disorders such as oppositional defiant disorder (ODD), conduct disorder, and possibly mood disorders such as depression, mania, and anxiety, as well as substance misuse
What are the non-drug treatment for ADHA?
- balanced diet, good nutrition and regular exercise
- environmental modifications such as changes to seating arrangements lighting and noise etc.
ADHD focused psychological interventions which may involve elements of, or a complete course of cognitive behavioural therapy (CBT) may be effective in patients who have refused drug treatment, have difficulty with adherence, are intolerant of, or unresponsive to drug treatment. In patients who have benefited from drug treatment, but whose symptoms are still causing significant impairment in at least one area of function (such as interpersonal relationships, education and occupational attainment, and risk awareness), consider a combination of non-drug treatment with drug treatment.
Who should drug treatment be prescribed by for ADHD?
Drug treatment should be initiated by a specialist trained in the diagnosis and management of ADHD.
Following dose stabilisation, continuation and monitoring of drug treatment can be undertaken by the patient’s general practitioner under a shared care arrangement.
In which patients should drug treatment be started on for ADHD?
Treatment should be started in patients with ADHD whose symptoms are still causing significant impairment in at least one area of function, despite environmental modifications.
Does having an anxiety disorder, tic disorder, or autism spectrum disorder affect treatment options for ADHD?
No - should be treated the same
What is the first line drug treatment for ADHD?
Lisdexamfetamine (Elvanse) or methylphenidate are recommended as first line
If symptoms have not improved following a 6-week trial of either drug, switching to the alternative first-line treatment should be considered
If a patient cannot tolerate lisdexamfetamine (elvanse) then what can be tried (unlicensed) if they were having beneficial response from lisdexamfetamine?
Dexamfetamine for those who cannot tolerate lisdexamfetamine’s longer duration of effect.
Are immediate formulations or modified release preparations preferred in ADHD?
Modified-release preparations of stimulants are preferred because of their pharmacokinetic profile, convenience, improved adherence, reduced risk of drug diversion (drugs being forwarded to others for non-prescription use or misuse), and the lack of need to be taken to work. Immediate-release preparations can be given when more flexible dosing regimens are required, or during initial dose titration.
In patients who are intolerant to both methylphenidate hydrochloride and lisdexamfetamine mesilate, or who have not responded to separate 6-week trials of both drugs, what drug can be considered next?
- A non-stimulant
Atomoxetine
How often should treatment for ADHD be reviewed by the specialist?
At least once a year and trials of treatment free periods or dose reductions should be considered where appropriate.
What drug class is Atomoxetine?
Centrally acting sympthomimetics (CNS Stimulant)
What are some of the brand names for methyphendidate?
- Concerta XL
- Quasym XL
- Medikinet XL
- Xaggitin XL
What is the brand name for lisdexamfetamine?
Elvanse
Which drug can be given to children for whom stimulants are not suitable, not tolerated or ineffective (initiated under specialist supervision)?
Guanfacine (Alpha2 adrenoreceptor agonist)
what are the monitoring requirements of atomoxetine?
- Monitoring requirements: monitor patient for worsening of anxiety, depression or tics. Pulse, blood pressure psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment and 6 months thereafter.
What is tics?
Tics are sudden twitches, movements, or sounds that people do repeatedly. People who have tics cannot stop their body from doing these things. For example, a person with a motor tic might keep blinking over and over again. Or, a person with a vocal tic might make a grunting sound unwillingly
With dexamfetamine use or lisdexamfetamine use what should you do if tics or tourette syndrome occurs?
Discontinue treatment
What is Tourette syndrome?
Tourette Syndrome (TS) is a condition of the nervous system. TS causes people to have “tics”. Tics are sudden twitches, movements, or sounds that people do repeatedly. People who have tics cannot stop their body from doing these things
What is bipolar disorder?
It is a condition that affects moods, which can swing from one extreme to another.
People with bipolar disorder often have periods or episodes of:
- Depression (feeling very low and lethargic
- Mania (feeling very high and overactive)
Which class of drugs are used in bipolar disorder to manage acute episodes of mania or hypomania and to prevent recurrence?
Antimanic drugs
In bi-polar disorder, antidepressants can be used to treat co=existing bipolar depression, but should be avoided in which patients?
Patients with rapid-cycling bipolar disorder
- a recent history of mania or hypomania or with rapid mood fluctuations
(Consider stopping the antidepressant drug if the patient develops mania or hypomania
Which antipsychotics can be used in the treatment of acute episodes of mania or hypomania?
- Haloperidol
- Olanzapine
- Quetiapine
- Risperidone
If response to antipsychotics is inadequate then which drugs may be added?
Lithium or sodium valproate
what about in patients already taking prophylactic treatment with lithium or valproate?
if there is no improvement despite optimising the dose of lithium or valproate, an antipsychotic drug can be added to treat the acute episode of mania or hypomania.
What is the drug asenapine and what is it licensed to be used in?
It is a second generation antipsychotic drug, it is licensed for the treatment of moderate to severe manic episodes associated with bipolar disorder
Which antipsychotic can be used for the long-term management of bipolar disorder?
- Olanzapine
- it is licensed for the prevention of recurrence in patients whose manic episode has responded to olanzapine therapy
When discontinuing antipsychotic drugs - how should they be withdrawn?
The dose should be reduced gradually over at least 4 weeks to minimise the risk of recurrence
What use do benzodiazepines have in treatment of bipolar disorder?
- use of benzodiazepines (such as lorazepam) may be helpful in the initial stages of treatment for behavioural disturbances or agitation.
- They should not be used for long periods because of the risk of dependence.
What are the two types of lithium salts?
Lithium carbonate
Lithium Citrate
What is the use of lithium in bipolar disorder?
Lithium is used for the treatment of acute episodes of mania or hypomania in bipolar disorder.
Lithium is also used for the long-term management of bipolar disorder to prevent recurrence of acute episodes.
what must the decision to give prophylactic lithium be based on?
must be based on careful consideration of the likelihood of recurrence in the individual patient, and the benefit of treatment weighed against the risks
How long can it take for the full prophylactic effect of lithium to occur?
- six to twelve months after initiation of therapy
If lithium is not tolerated or contra-indicated then which drug is used as an alternative?
Valproate (valproic acid (as the semisodium salt) and sodium valproate)
It is used for the treatment of manic episodes associated with bipolar disorder if lithium is not tolerated or contra-indicated.
Valproate is also used for the long-term management of bipolar disorder to prevent recurrence of acute episodes, in combination with lithium if treatment with lithium alone is ineffective, or as monotherapy if lithium is not tolerated or contra-indicated.
Can valproic acid or sodium valproate be used during pregnancy in patients with bipolar disorder?
No
What role does carbamazepine have in bipolar disorder?
It is licensed for the long-term management of bipolar disorder, to prevent recurrence of acute episodes in patients unresponsive to lithium therapy.
What has long-term use of lithium been associated with?
- thyroid disorders and mild cognitive and memory impairment
thyroid function should be monitored every 6 months- more frequently if there is evidence of deterioration
When should samples of lithium be taken after giving a dose?
12 hours after a dose
What is the target therapeutic range of lithium?
- 4-1mmol/L (lower end of the range for maintenance therapy and elderly patients).
- 8-1mmol/L is recommended for acute episodes of mania, and for patients who have previously relapsed or have sub-syndromal symptoms.
What is the moniotring frequency of lithium?
Routine serum-lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, then every 3 months for the first year then every 6 months thereafter.
Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months during treatment and more often if there is evidence of impaired renal or thyroid function, or raised calcium levels.
How should lithium be withdrawn when required?
Gradually over at least 4 weeks (preferably over 3 months)
What is depression?
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning.
With antidepressant drugs for depression what is usually the first benefit of therapy?
Improvement
What is dysthymia?
(lower grade chronic depression) - Typically of at least 2 years duration.
Antidepressant drugs are also effective for dysthymia
Can antidepressant drugs be used in mild depression?
No - should not be used routinely in mild depression and psychological therapy should be considered initially; however, a trial of antidepressant therapy may be considered in cases refractory to psychological treatments or in those associated with psychosocial or medical problems.
What are the major classes of antidepressant drugs?
- Tricyclic and related antidepressants
- selective serotonin re-uptake inhibitors (SSRIs)
- Monoamine oxidase inhibitors (MAOIs)
Is efficacy between different classes of antidepressant drugs large?
No there is little to choose between them in terms of efficacy.
Choice should be based on the individual patient’s requirements, including the presence of concomitant disease, existing therapy, suicide risk, and previous response to antidepressant therapy.
Since there may be an interval of 2 weeks before antidepressant action takes place, in severe depression what else may be required to be given?
electroconvulsive treatment may be required in severe depression when delay is hazardous or intolerable.
During the first few weeks of treatment, there is an increased potential for what?
there is an increased potential for agitation, anxiety, and suicidal ideation.
Which anti-depressant drug should be considered as first-line for treatment of depression?
SSRIs - 1st line
They are better tolerated and are safer in overdose than other classes of antidepressants.
In patients with unstable angina or who have had a recent myocardial infarction, which anti-depressant drug has been shown to be safe?
Sertraline
Is tricyclic antidepressants more effective than SSRIs?
They have similar efficacy to SSRIs but are more likely to be discontinued because of side-effects; toxicity in overdose is also a problem
SSRIs are less sedating and have fewer antimuscarinic and cardiotoxic effects than tricyclic antidepressants.
Why are MAOIs less frequently used?
They have dangerous interactions with some foods and drugs and should be reserved for use by specialists
Why must antipsychotics or anxiolytics be used with caution in depression?
They may mask the true diagnosis
but they are useful adjuncts in agitated patients
what is St John’s wort sold in public to treat?
St John’s wort (Hypericum perforatum) is a popular herbal remedy on sale to the public for treating mild depression
Why should St John’s wort not be prescribed or recommended for depression?
because St John’s wort can induce drug metabolising enzymes and a number of important interactions with conventional drugs, including conventional antidepressants, have been identified
Furthermore, the amount of active ingredient varies between different preparations of St John’s wort and switching from one to another can change the degree of enzyme induction.
If a patient stops taking St John’s Wort, what will happen to the concentration of interacting drugs?
the concentration of the interacting drugs may increase, leading to toxicity
(St John’s Wort is a metabolising enzyme inducer)
At the start of antidepressant treatment, how often should patients be reviewed?
- Every 1-2 weeks at the start
How long should treatment with antidepressant be continued before considering whether to switch due to lack of efficacy?
Treatment should be continued for at least 4 weeks
(6 weeks in the elderly)
In cases of partial response, continue for a further 2-4 weeks.
Following remission, how long should antidepressant treatment be continued for?
- should be continued at the same dose for at least 6 months (about 12 months in the elderly)
- or for at least 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high)
How long should maintenance treatment be continued for patients with a history of depression?
For at least 2 years
What electrolyte imbalance has been associated with all antidepressants?
- Hyponatraemia
(usually in the elderly and possibly due to inappropriate secretion of antidiuretic hormone)
More frequently reported with SSRIs than other antidepressants.
While taking antidepressants what signs can indicate hyponatraemia?
If patient develops:
- Drowsiness
- Confusion
- Convulsions
What is serotonic syndrome?
Serotonin syndrome or serotonin toxicity is a relatively uncommon adverse drug reaction caused by excessive central and peripheral serotonergic activity. Onset of symptoms, which range from mild to lifethreatening, can occur within hours or days following the initiation, dose escalation, or overdose of a serotonergic drug, the addition of a new serotonergic drug, or the replacement of one serotonergic drug by another without allowing a long enough washout period in-between, particularly when the first drug is an irreversible MAOI or a drug with a long half-life. Severe toxicity, which is a medical emergency, usually occurs with a combination of serotonergic drugs, one of which is generally an MAOI
what are the characteristic symptoms of serotonin syndrome?
The characteristic symptoms of serotonin syndrome fall into 3 main areas, although features from each group may not be seen in all patients—neuromuscular hyperactivity (such as tremor, hyperreflexia, clonus, myoclonus, rigidity), autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea), and altered mental state (agitation, confusion, mania).
What is the treatment for serotonin syndrome?
Treatment consists of withdrawal of the serotonergic medication and supportive care; specialist advice should be sought.
What is the next step in depression management if patient fails to respond to first line SSRI?
Failure to respond to initial treatment with an SSRI may require an increase in the dose, or switching to a different SSRI or mirtazapine.
Other second-line choices include lofepramine, moclobemide, and reboxetine.
Other tricyclic antidepressants and venlafaxine should be considered for more severe forms of depression; irreversible MAOIs should only be prescribed by specialists.
What may failure to respond to a second antidepressant require the addition of?
Failure to respond to a second antidepressant may require the addition of another antidepressant of a different class, or use of an augmenting agent (such as lithium, aripiprazole [unlicensed], olanzapine [unlicensed], quetiapine, or risperidone [unlicensed]), but such adjunctive treatment should be initiated only by doctors with special experience of these combinations. Electroconvulsive therapy may be initiated in severe refractory depression.
What is the management of acute anxiety?
Management of acute anxiety generally involves the use of a benzodiazepine or buspirone hydrochloride.
For chronic anxiety (of longer than 4 weeks’ duration) it may be appropriate to use?
Antidepressants
Combined therapy with a benzodiazepine may be required until the antidepressant takes effect.
For patients with generalised anxiety disorder (a form of chronic anxiety) what should be offered?
should be offered psychological treatment before initiating an antidepressant. If drug treatment is needed, an SSRI such as escitalopram, paroxetine, or sertraline [unlicensed], can be used
Duloxetine and venlafaxine (serotonin and noradrenaline reuptake inhibitors (SNRIs)) are also recommended for the treatment of generalised anxiety disorder
if the patient cannot tolerate SSRIs or SNRIs (or if treatment has failed to control symptoms), pregabalin can be considered.
What are the drug treatments for panic disorders?
Panic disorder is treated with SSRIs; clomipramine hydrochloride [unlicensed] or imipramine hydrochloride [unlicensed] can be used second-line. Venlafaxine, an SNRI, is also licensed for panic disorder.
What are obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder treated with?
SSRIs
Clomipramine hydrochloride can be used second-line for obsessive-compulsive disorder.
What type of anxiety is meclobemide licensed for?
Moclobemide is licensed for the treatment of social anxiety disorder.
How do tricyclic and related antidepressants work?
They block the re-uptake of both serotonin and noradrenaline, although to different extents
What is clomipramine more selective towards compared to imipramine?
Clomipramine - more selective for serotonergic transmission
Imipramine - more selective for noradrenergic transmission
What can tricyclic and related antidepressants be divided into according to what?
Those with additional sedative properties and those that are less sedating.
What do agitated and anxious patient tend to respond best to?
Sedative compounds
What about withdrawn and apathetic patients?
tend to respond better to less sedative ones
Which tricyclic and related antidepressants have sedative properties?
amitriptyline hydrochloride, clomipramine hydrochloride, dosulepin hydrochloride, doxepin, mianserin hydrochloride, trazodone hydrochloride, and trimipramine
Which tricyclic and related antidepressants have less sedative properties?
Those with less sedative properties include imipramine hydrochloride, lofepramine, and nortriptyline.
Tricyclic and related antidepressants also have varying degrees of what?
varying degrees of antimuscarinic side-effects and cardiotoxicity in overdosage, which may be important in individual patients.
What is lofepramine (less sedating) associated with?
Lofepramine has a lower incidence of side-effects and is less dangerous in overdosage but is infrequently associated with hepatic toxicity
Which tricyclic and related antidepressant has the most antimuscarinic side effects?
Imipramine hydrochloride is also well established, but has more marked antimuscarinic side-effects than other tricyclic and related antidepressants
Is amitriptyline recommended for the treatment of depression? if not then why?
Amitriptyline hydrochloride and dosulepin hydrochloride are effective but they are particularly dangerous in over-dosage and are not recommended for the treatment of depression; dosulepin hydrochloride should be initiated by a specialist.
Is modified release of antidepressants required?
It is unnecessary as the long half-life of tricyclic antidepressant drugs allows once-daily administration; usually at night
Have studies shown tricyclic antidepressants to be useful in children?
No
In which conditions in elderly can use of tricyclic antidepressants ?
if prescribed in those with dementia, narrow angle glaucoma, cardiac conduction abnormalities, prostatism, or history of urinary retention (risk of worsening these conditions);
if initiated as first-line antidepressant treatment (higher risk of adverse drug reactions than with SSRIs or SNRIs).
Why are monoamine-oxidase inhibitors used much less frequently than tricylic and related antidepressants, or SSRIs and related antidepressants?
because of the dangers of dietary and drug interactions and the fact that it is easier to prescribe MAOIs when tricyclic antidepressants have been unsuccessful than vice versa.
Which MOAI has a greater stimulant action?
Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid and is more likely to cause a hypertensive crisis.
Which MOAIs are likely to cause hepatoxicity?
Isocarboxazid and phenelzine are more likely to cause hepatotoxicity than tranylcypromine.
Is Meclobemide (MAOI) used 1 st line?
Moclobemide should be reserved as a second line treatment.
It is also used for social anxiety disorder
In which patients are MAOIs said to respond best in?
Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features are said to respond best to MAOIs.
However, MAOIs should be tried in any patients who are refractory to treatment with other antidepressants as there is occasionally a dramatic response.
How long can it take for response to treatment with MAOI to take effect?
Response to treatment may be delayed for 3 weeks or more and may take an additional 1 or 2 weeks to become maximal.
When a patient has been on MAOI and this has been stopped, how long should you wait before another antidepressant can be started due to drug-drug interaction?
- should not be started for 2 weeks after treatment with MAOIs has been stopped
(3 weeks if starting clomipramine or imipramine).
There is specific timings when an MAOI should not be started when previous antidepressant has been stopped. what are these?
an MAOI should not be started until:
at least 2 weeks after a previous MAOI has been stopped (then started at a reduced dose)
at least 7–14 days after a tricyclic or related antidepressant (3 weeks in the case of clomipramine or imipramine) has been stopped
at least a week after an SSRI or related antidepressant (at least 5 weeks in the case of fluoxetine) has been stopped
What role does flupentixol (Fluanxol) have in manegement of depression?
The thioxanthene flupentixol (Fluanxol ®) has antidepressant properties when given by mouth in low doses. Flupentixol is also used for the treatment of psychoses
Which drug is recommended in patients whose condition has responded inadequately to 2 antidepressants within the current episode?
Vortioxetine, an antidepressant thought to directly modulate serotonergic receptor activity and inhibit the re-uptake of serotonin
Which drug is used in treatment-resistant depression?
- Tryptophan
It should be initiated by hospital specialists
Which drug class does agomelatine fall under?
Melatonin receptor agonist
What is the MOA of agomelatine?
It is a melatonin receptor agonist and a selective serotonin-receptor antagnoist; it does not affect the uptake of serotonin, noradrenaline or dopamine
What is the indication of agomelatine?
Major depression
What is the MOA of MOAIs?
MAOIs inhibit monoamine oxidase, thereby causing an accumulation of amine neurotransmitters
Which MOAI are irreversible?
- Isocarboaxazid
- Phenelzine
- Tranylcypromine
Which MOAIs are reversible?
Meclobemide
Which drug is a noradrenaline reuptake inhibitor?
Raboxetine
What are the contraindications of SSRIS?
Pooly controlled epilepsy
Should not be used in patients if they enter a manic phase
Which electroylte imbalance can SSRIs affect?
Hyponatraemia
What prolongation can SRIs cause?
QT prolongation
Can SSRIs cause erectile dysnfunction?
Yes
Name a list of SSRIs?
Citaloptam Escitaloptam Fluoxetine Fluvoxamine maleate Paroxetine Sertraline
What is a contraindication for citalopram and escitaloptam?
QT prolongation
Whi h SSRI is livensed for major depression?
Paroxetine
What does SNRI stand for?
Serotonin and noradrenaline reuptake inhibitors
Give a list of SNRIs?
Duloxetine
Venlafaxine
Give an example of a serotonin reuptake inhibitor?
Trazadone hydrochloride
Give examples of tetracyclic antidepressants?
Mianserin hydrochloride
Mirtazepine
Give examples of tricyclic antidepressants?
Amitriptyline Clomipramine Dosulepin Doxepin Imipramine Lofepramine Nortriptyline Trimipramine
What is the mechanism of action of tryptophan?
Tryotophan is an essential dietary amino acid, and is a precusor of serotonin; it re-establishes the inhibitory action of serotonin on the amygdaloid nuclei, thereby reducing feelings of anxiety and depression.
Which first generstion antipsychotic can be used to control of deviant antisocial (inappropriate) sexual behaviour?
Benperidol
How long should treatment with anti-depressants be continued for atleast before considering change?
-4 weeks
6 weeks in elderly
Why is SSRIs (e.g. Sertraline) used as first-line in depression?
As they are safer in overdose than other antidepressants
What is a summary of the treatment steps of depression?
- SSRI 1st line
- If a patient fails to respond to initial treatment with an SSRI, consider switching to a different SSRI or Mirtazapine
- Second-line treatment choices include Venlafaxine (serotonin and noradrenaline re-uptake inhibitor) + Tricyclics. Failure to respond to a second antidepressant may require addition of an augmenting agent (top-up drug) such as Lithium or Olanzapine.
- ECT may be initiated in severe refractory depression.
What do tricyclic antidepressants block the reuptake of?
- Both serotonin and noradrenaline
Which is more sedative, amitriptyline or nortriptyline?
- Amitriptyline
Would you use sedative TCAs or non sedative for agitated and anxious patients?
- If a patient fails to respond to initial treatment with an SSRI, consider switching to a different SSRI or Mirtazapine
- Second-line treatment choices include Venlafaxine (serotonin and noradrenaline re-uptake inhibitor) + Tricyclics. Failure to respond to a second antidepressant may require addition of an augmenting agent (top-up drug) such as Lithium or Olanzapine.
- ECT may be initiated in severe refractory depression.
Amitriptyline can cause antimuscarinic side effects - what side effects are they?
- dry mouth
- blurred vision
- Urinary retention and constipation
Which drugs can TCAs interact with?
Warfarin - either increasing or decreasing INR
It may also interact with epileptics
Which SSRI has been proven to be effective in children and adolescents?
Only fluoxetine
What are the symptoms of serotonin syndrome?
Symptoms include neuromuscular hyperactivity (tremor, muscle spasm, rigidity, etc.), autonomic dysfunction (tachycardia, hyper/hypotension, hyperthermia, etc.) and altered mental state (agitation, confusion and mania
Which drugs may SSRIs interact with?
SSRIs may interact with drugs which increase the risk of bleeding including Warfarin, Antiepileptics and other antidepressants/antipsychotics.
Which SSRIs have a higher risk of withdrawal reactions?
- Paroxetine and venlafaxine
If a patient was taking SSRI and this got stopped, how long should they wait before starting MAOI?
At a week after an SSRI has been stopped (at least 5 weeks in the case of fluoxetine)
Which signs might be a sign of hepatoxicity which patients should be warned to look out for that are on agomelatine?
- Dark Urine
- Light coloured stools
- Jaundice
- Pruiritis
What are antipsychotics known as?
Neuroleptics - previously known as major tranquillisers
What can antipsychotics be used for?
A number of mental health disorders
- Mainly schizophrenia and bipolar disorder (sometimes called manic depression),
- also may be used in severe or difficult to treat anxiety or depression
What is schizophrenia?
Schizophrenia is a serious mental disorder in which people interpret reality abnormally.
What are some symptoms of schizophrenia?
The symptoms of psychosis and schizophrenia are usually divided into ‘positive symptoms’ such as hallucinations and delusions, and ‘negative symptoms’ such as emotional apathy and social withdrawal.
Which symptoms do antipsychotics tend to be better at treating?
Antipsychotic drugs are effective in the treatment of acute schizophrenic episodes; they are more effective at alleviating positive symptoms than negative symptoms.
What is considered first line for schizophrenia?
An oral antipsychotic drug in combination with psychological therapy should be offered to patients with schizophrenia. The choice of drug depends on factors such as the potential to cause extrapyramidal symptoms (including akathisia), cardiovascular adverse effects, metabolic adverse effects (including weight gain and diabetes), hormonal adverse effects (including increase in prolactin concentration), and patient and carer preference.
Patient should receive an antipsychotic drug at an optimum dose for how long before it is deemed ineffective?
optimum dose for 4-6 weeks
Can more than one antipsychotic be prescribed at a time?
No should be avoided except in exceptional circumstances (e.g. clozapine augmentation or when changing medication during titration) because of the increased risk of adverse effects such as extrapyramidal symptoms, QT-interval prolongation, and sudden cardiac death.
When should clozapine be considered for the treatment of schizophrenia?
Clozapine should be offered if schizophrenia is not controlled despite the sequential use of at least 2 different antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for an adequate duration.
What if respond is inadequate to clozapine?
If symptoms do not respond adequately to an optimised dose of clozapine, consider other causes of non-response (e.g. adherence to therapy, concurrent use of other drugs), review diagnosis, and check plasma-clozapine concentration before adding a second antipsychotic drug to augment clozapine; allow 8–10 weeks’ treatment to assess response. Patients must be registered with a clozapine patient monitoring service.
In which patients can a long-acting depot injectable antipsychotic drugs be considered in with psychosis and schizophrenia?
Where it is a clinical priority to avoid non-adherence
What are first generation antipsychotics also known as?
- Also known as typical or conventional
How do 1st generation antipsychotics predominantly work?
Predominantly work by blocking dopamine D2 receptors
They are more likely to cause a range of side-effects, particularly acute extrapyramidal symptoms and hyperprolactinaemia.
Give examples of first generation antipsychotics?
phenothiazine derivatives (chlorpromazine hydrochloride, fluphenazine decanoate, levomepromazine, pericyazine, prochlorperazine, promazine hydrochloride, and trifluoperazine), the butyrophenones (benperidol and haloperidol), the thioxanthenes (flupentixol and zuclopenthixol), the diphenylbutylpiperidines (pimozide) and the substituted benzamides (sulpiride).
How do second-generation antipsychotic drugs work?
(also referred to as atypical) act on a range of receptors in comparison to first-generation antipsychotic drugs
They work by blocking D2 dopamine receptors as well as serotonin receptor antagonist action.
5-HT2A subtype of serotonin receptor is most commonly involved
What side effects are second generation anti-psychotics associated with?
generally associated with a lower risk for acute extrapyramidal symptoms and tardive dyskinesia; the extent varies between individual drugs. However, second-generation antipsychotic drugs are associated with several other important adverse effects, such as weight gain and glucose intolerance.
Give examples of second generation anti-sychotics?
amisulpride, aripiprazole, asenapine, cariprazine, clozapine, lurasidone hydrochloride, olanzapine, paliperidone, quetiapine, and risperidone.
What is a high dose antipsychotic defined as?
AS a total daily dose of a single antipsychotic drug which exceeds the maximum licensed dose with respect to the age of the patient and indication being treated, and a total daily dose of two or more antipsychotic drugs which exceeds the maximum licensed dose using the percentage method
Is there good evidence to support high doses of antipsychotics being more effective?
There is no robust evidence that high doses of antipsychotic drug treatment is any more effective than standard doses for the treatment of schizophrenia.
When prescribing an antipsychotic drug administration in an emergency situation (e.g. for rapid tranquillisation) what is the aim?
the aim of treatment is to calm and sedate the patient without inducing sleep.
If a high dose antipsychotics has been given in an emergency situation, how often should patient be monitored?
Monitor patient every 15 minutes
The use of antipsychotic drugs in the elderly has been associated with what?
The use of antipsychotic drugs are associated with a small increased risk of mortality and an increased risk of stroke or transient ischaemic attack
Is antipsychotics drugs recommended in elderly patients with dementia?
should not be used in elderly patients with dementia, unless they are at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress.
If antipsychotics are used in the elderly, how often should this be reviewed?
- Regularly, at least every 6 weeks (earlier for in patients)
In patients with learning disabilities who are taking antipsychotic drugs and not experiencing psychotic symptoms, what considerations should be taken into account:
a reduction in dose or the discontinuation of long-term antipsychotic treatment;
review of the patient’s condition after dose reduction or discontinuation of an antipsychotic drug;
referral to a psychiatrist experienced in working with patients who have learning disabilities and mental health problems;
annual documentation of the reasons for continuing a prescription if the antipsychotic drug is not reduced in dose or discontinued.
Is there a big difference in efficacy between each of the antipsychotics drugs?
No only little difference (other than clozapine)
Are extra-pyramidal side effects of antipsychotics - dose related?
YEs and are most liekly to occur with high doses of high-potency first generation antipsychotics drugs such as piperazine phenothiazines, benperidol and haloperidol), and the first generation depot preparations.
Are extra-pyramidal side effects more common with 1st or 2nd generation antipsychotics?
More common with 1st generation antipsychotics.
What are the extrapyramidal side effects?
- parkinsonian symptoms (including bradykinesia, tremor), which may occur more commonly in elderly females or those with pre-existing neurological damage such as stroke, and may appear gradually;
- dystonia (uncontrolled muscle spasm in any part of the body), which occurs more commonly in young males; acute dystonia can appear within hours of starting antipsychotics;
- akathisia (restlessness), which characteristically occurs within hours to weeks of starting antipsychotic treatment or on dose increase and may be mistaken for psychotic agitation;
- tardive dyskinesia (abnormal involuntary movements of lips, tongue, face, and jaw), which can develop on long-term or high-dose therapy, or even after discontinuation; in some patients it can be irreversible.
Can anti-muscarinic drugs be used with antipsychotic drugs?
Although antimuscarinic drugs can relieve symptom burden, they should not be routinely prescribed for prophylaxis with antipsychotic drugs.
What is the most serious manifestation of late-onset extra-pyramidal symptoms?
Tardive dyskinesia is the most serious manifestation of late-onset extrapyramidal symptoms for which there is no satisfactory treatment
Tardive dyskinesia associated with antipsychotic use is more common in men or female?
it occurs more commonly in elderly females
Why do antipsychotics lead to side effect of hyperprolactinaemia?
Most antipsychotic drugs, both first- and second-generation, increase prolactin concentration to some extent because dopamine inhibits prolactin release.
Which antipsychotic is a dopamine-receptor partial agonist and reduces prolactin concentration?
Aripiprazole reduces prolactin concentration in a dose-dependent manner as it is a dopamine-receptor partial agonist.
Which antipsychotics are most likely to cause symptomatic hyperprolactinaemia?
- Risperidone
- amisulpride
- first generation antipsychotic drugs
With which antipsychotic drugs is hyperprolactinaemia very rare?
- aripiprazole
- asenapine
- Cariprazine
- Clozapine
- Quetiapine
What are the clinical symptoms of hyperprolactinaemia?
sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea, and a possible increased risk of breast cancer.
What is galactorrhoea?
Galactorrhoea is milky secretion from the breasts. The term usually refers to milk secretion not due to breastfeeding.
Is sexual dysfunction reported as a side effect of all antipsychotics?
Yes
Which antipsychotics have a higher chance of causing erectile dysfunction?
- Risperidone
- Haloperidol
- Olanzapine
Which antipsychotics are associated with the lowest risk of sexual dysfunction?
- Aripiprazole
- Quetiapine
What is expert advice if someone on antipsychotic is experiencing sexual dysfunction?
Expert sources advise to consider dose reduction or discontinuation (where appropriate), or switching medication if sexual dysfunction is thought to be antipsychotic-induced.
Which cardiovascular side effects are antipsychotics associated with?
- tachycardia
- arrhythmias
- Hypotension
With which antipsychotics is QT prolongation risk higher with?
QT-interval prolongation is a particular concern with pimozide. Overall risk is probably dose-related but there is also a higher probability of QT-interval prolongation in patients using any intravenous antipsychotic drug, or any antipsychotic drug or combination of antipsychotic drugs with doses exceeding the recommended maximum.
Which antipsychotic drugs have a low tendency to prolong QT interval?
aripiprazole, asenapine, clozapine, flupentixol, fluphenazine decanoate, loxapine, olanzapine, paliperidone, prochlorperazine, risperidone, and sulpiride.
Is postural hypotension common with antipsychotic drugs?
Postural hypotension is a common cardiac side-effect of antipsychotic drugs, usually presenting acutely during the initial dose titration; however, it can also be a chronic problem.
Which antipsychotics are most likely to cause postural hypotension?
The second-generation antipsychotics most likely to cause postural hypotension are clozapine and quetiapine.
Slow dose titration is commonly used to minimise postural hypotension.
Is schizophrenia associated with insulin resitance and diabetes?
Schizophrenia is associated with insulin resistance and diabetes; the risk of diabetes is probably increased in all patients with schizophrenia who take antipsychotic drugs.
Do first or second generation antipsychotics have a higher chance of causing diabetes?
Some evidence suggests first-generation antipsychotic drugs are less likely to cause diabetes than second-generation antipsychotic drugs, and of the first-generation antipsychotic drugs, fluphenazine decanoate and haloperidol have the lowest risk. Amisulpride and aripiprazole have the lowest risk of diabetes of the second-generation antipsychotic drugs.
Which antipsychotics are known to cause weight gain?
All antipsychotic drugs may cause weight gain, but the risk and extent varies. Clozapine and olanzapine commonly cause weight gain.
Which antipsychotics are least likely to cause weight gain?
Amisulpride, asenapine, aripiprazole, cariprazine, haloperidol, lurasidone hydrochloride, sulpiride, and trifluoperazine are least likely to cause weight gain.
What is a rare but potentially fatal side effect of all antipsychotics?
Neuroleptic malignant syndrome (hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with fever, tachycardia, labile blood pressure, and sweating) is a rare but potentially fatal side-effect of all antipsychotic drugs.
What is the recommendation if patient is experiencing neuroleptic malignant syndrome?
Expert sources advise discontinuation of the antipsychotic drug is essential for at least 5 days, preferably longer. The signs and symptoms of neuroleptic malignant syndrome should be allowed to resolve completely. Bromocriptine and dantrolene have been used for treatment.
How often should weight be monitored for antipsychotics?
Weight should be measured at the start of therapy with antipsychotic drugs, then weekly for the first 6 weeks, then at 12 weeks, at 1 year, and then yearly.
What other monitoring iss requried?
Fasting blood glucose, HbA1c, and blood lipid concentrations should be measured at baseline, at 12 weeks, at 1 year, and then yearly. Prolactin concentrations should also be measured at baseline.
Before initiating antipsychotic drugs, an ECG may be required, particularly if physical examination identifies cardiovascular risk factors (e.g. high blood pressure), if there is a personal history of cardiovascular disease, or if the patient is being admitted as an inpatient.
Blood pressure monitoring is advised before starting therapy, at 12 weeks, at 1 year and then yearly during treatment and dose titration of antipsychotic drugs.
Expert sources advise to monitor full blood count, urea and electrolytes, and liver function tests at the start of therapy with antipsychotic drugs, and then yearly thereafter
Are antipsychotic depot injections associated with higher incidence of adverse-effects such as extrapyramidal reactions?
Yes with first generation depot injections
Which second generation antipsychotic depot injection preparations do EPSs occur less freqeuntly?
- Aripiprazole
- paliperidone
- Risperidone
- Olanzapine embonate
What is the first generation antipsychotic depot injection that may be more effective in preventing relapses than other first-generation antipsychotic depot preparations?
zuclopenthixol decanoate may be more effective in preventing relapses than other first-generation antipsychotic depot preparations.
What clinical monitoring is indicated in children taking antipsychotics?
Regular clinical monitoring of endocrine function should be considered when children are taking antipsychotics known to increase prolactin levels; this includes measuring weight and height, assessing sexual maturation, and monitoring menstrual function.
Is photosensitisation associated with low or high doses of antipsychotics?
May occur with higher doses and patients should avoid direct sunlight.
List a few examples of first generation antipsychotics?
Chlorpromazine Flupentixol Haloperidol Loxapine Pericyazine (periciazine) prochlorperazine Pimozide Sulpride Trifluoperazine Zuclopenthixol
Which first generation antipsychotics are available as depot injections?
Flupentixol decanoate
Fluphenazine
Haloperidol
Zuclopenthixol decanoate
Give examples of second generation antipsychotics?
Amisulpride Aripiprazole Cariprazine Clozapine Lurasidone Olanzapine Paliperidoe Quetiapine Risperidone
Which second generation antipsychotics are available as depot injection
Olanzapine embonate
What has clozapine been associated with?
Varying degrees of impariment of intestinal peristalsis
MHRA recommends clozapine blood concentrations are monitored when:
When a patient stops smoking or switches to an e-cigarette
concomitant medicines may interact to increase blood clozapine levels
if a patient has pneumonia or other serious infection
reduced clozapine metabolism suspected
toxicity is suspected
What monitoring is required due to agranulocytosis induced by clozapine?
- Leucocyte and differential blood counts must be normal before starting, monitor counts every week for 18 weeks and then at least every 2 weeks and if clozapine continued and blood count stable after 1 year at least every 4 weeks (and 4 weeks after discontinuation)/
If patient taking clozapine gets myocarditis or cardiomyopathy then what should be done?
Treatment should be discontinued
What is cerebral palsy?
It is a group of permanent, non-progressive abnormalities of the developing fetal or neonatal brain that lead to movement and posture disorders, causing activity limitation and functional impact.
What are some symptoms of characteristics of cerebral palsy?
disturbances of sensation, perception, cognition, communication and behaviour, epilepsy, and secondary musculoskeletal problems (such as muscle contracture and abnormal torsion).
Is cerebral palsy curable?
No it is not and the comorbidities can impact on many areas of participation and quality of life, particularly eating, drinking, comfort and sleep.
What is motor neurone disease?
IT is a neurodegenerative condition affecting brain and spinal cord.
Degeneration of the motor neurones leads to progressive muscle weakness;
What are the symptoms of motor neurone disease?
- muscle cramps, wasting and stiffness, loss of dexterity, reduced respiratory function and cognitive dysfunction.
What is the most common form of motor neurone disease?
amyotrophic lateral sclerosis
Patients suspected of having motor neurone disease should be referred to who?
Neurologist without delay
Is there a cure for motor neurone disease?
No - therefore aim of treatment focuses on maintaining functional ability and managing symptoms
Which drugs can be used for management of motor neurone disease?
Quinine [unlicensed indication] is recommended as first line treatment for muscle cramps. If quinine is ineffective, not tolerated or contra-indicated, baclofen [unlicensed indication] should be considered as second line treatment. Subsequent treatment options include tizanidine [unlicensed indication], dantrolene sodium [unlicensed indication] or gabapentin [unlicensed indication].
In patients with motor neurone disease suffering from Symptoms of muscle stiffness, spasticity or increased tone, what can be used to manage these?
baclofen, tizanidine, dantrolene sodium or gabapentin [unlicensed indication].
Which drug is recommended for excessive saliva in motor neurone disease?
- Glycopyrronium bromide in patients who have cognitive impairment as it has fewer central nervous system side effects
Which drug is licensed to be used in patients with amyotrophic lateral sclerosis to extend life?
Riluzole to extend life or to extend the time to mechanical ventilation
In patients with hepatic impairment, all antipsychotics drugs can cause what?
Precipitate coma
What is dystonia?
Abnormal face + body movements
What is dyskinesia?
Impaired voluntary movements
Pimozide should not be given with which other drugs?
should not be given with other antipsychotics, TCAs or other drugs which prolong the QT interval and should not be given with drugs that cause electrolyte disturbances (especially diuretics)
What is the drug tetrabenazine mainly used to control?
Huntington’s chorea and related disorders
Can also be prescribed for the treatment of tardive dyskinesia if switching or withdrawing the causative antipsychotic drug is not effective
How does tetrabenazine work?
IT works by depleting nerve endings of dopamine
What limits use of tetrabenazine?
It is effective in only a proportion of patients and its use may be limited by the development of depression.
Which drug can be used to improve motor tics and symptoms of Tourette syndrome and related choreas?
Haloperidol
Pimozide (unlicensed)
sulpride (unlicesed)
What is Parkinson’s disease?
Parkinson’s disease is a progressive neurodegenerative condition resulting from the death of dopaminergic cells of the substantia nigra in the brain.
What do patients with Parkinson’s disease present with?
- Motor symptoms including hypokinesia, bradykinesia, rigidity, rest tremor and postural instability
What are the non-motor symptoms of Parkinson’s disease?
depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss
does someone diagnosed with Parkinson’s disease need to let DVLA know?
Yes and thier car insurer
What is the first line treatment for Parkinson’s disease?
In early stages of Parkinson’s disease, patients whose motor symptoms decrease their quality of life should be offered levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa).
What is the first line treatment for Parkinson’s where motor symptoms do not affect their quality of life?
a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).
Which risk of adverse reactions from antiparkinsonian drugs should be discussed with patients and their carers?
psychotic symptoms, excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists, and impulse control disorders with all dopaminergic therapy (especially dopamine-receptor agonists)
What is levodopa treatment associated with?
Levodopa treatment is associated with motor complications, including response fluctuations and dyskinesias.
Is the overall improvement in motor performance more noticeable with levodopa than with dopamine-receptor agonists?
More noticeable with levodopa however, motor complications are less likely to occur with dopamine receptor agonists when used alone long-term.
What is the risk of suddenly low concentrations of antiparkinsonian drug?
the potential risk for acute akinesia or neuroleptic malignant syndrome
What should Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy be offered?
offered a choice of non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine), monoamine oxidase B inhibitors (rasagiline or selegiline hydrochloride) or COMT inhibitors (entacapone or tolcapone) as an adjunct to levodopa.
When can a ergot-derived dopamine receptor agonist be considered?
An ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) should only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist.
If dyskinesia is still not adequately managed by modifying existing therapy, then which drug should be considered?
- Amantadine
What should happen to treatment for those who experience daytime sleepiness or sudden onset of sleep?
Should have their Parkinson’s drug treatment adjusted under specialist medical guidance
Whoch drug can be used in Parkinson’s for excessive daytime sleepiness?
If reversible pharmacological and physical causes have been excluded, modafinil should be considered to treat excessive daytime sleepiness, and treatment should be reviewed at least every 12 months.
For nocturnal akinesia in patient with Parkinson’s what is recommedned?
When treating nocturnal akinesia in patients with Parkinson’s disease, levodopa or oral dopamine-receptor agonists should be considered as first-line options and rotigotine as second-line (if both levodopa or oral dopamine-receptor agonists are ineffective).
For patients with Parkinson’s disease who develop postural hypotension, which drug should be considered instead?
midodrine hydrochloride should be considered as the first option and fludrocortisone acetate [unlicensed indication] as an alternative.
Can drug treatment for drooling of saliva in patients with PArkinsons’s disease be recommended?
Parkinson’s disease should only be considered if non-drug treatment such as speech and language therapy is not available or is ineffective.
Which drug is licensed to be used in the treatment of Parkinson’s disease dementia?
- Rivastigmine capsules or oral solution
What can patients with advanced Parkinson’s disease be offered?
Apomorphine hydrochloride as intermittent injections or continuous subcutaneous infusions
What can develop in patients with Parkinson’s who is on any dopaminergic therapy?
Impulse control disorders (compulsive gambling, hypersexuality, binge eating, or obsessive shopping)
When managing impulse control disorders, dopamine-receptor agonist doses should be reduced gradually and patients should be monitored for symptoms of dopamine agonist withdrawal. Specialist cognitive behavioural therapy should be offered if modifying dopaminergic therapy is not effective.
What is the drug ophenadrine hydrochloride used for?
Parkinsonism
What is the MAO of procyclidine?
Procyclidine exerts its antiparkinsonian action by reducing the effects of the relative central cholinergic excess that occurs as a result of dopamine deficiency.
Name few other drugs used in as an adjunct to co-beneldopa or co-careldopa in Parkinson’s disease with ‘end of dose’ motor fluctuations?
- Entacapone
- Opicapone
- Tolcapone
Give examples of dopamine precursors used in parkison’s disease?
- Co-beneldopa
- Co-careldopa
What has treatmetn with Co-beneldopa and co-careldopa been associated with? (WARNING??)
- Treatemtn with these drugs has been associated with impulse control disorders, including pathological gambling, binge eating, and hypersexuality.
Patients and their carers should be informed about the risk of impulse control disorders
Dopamine dysregulation syndrome
What is dopamine dysregulation syndrome?
Dopamine dysregulation syndrome (DDS) is a dysfunction of the reward system observed in some individuals taking dopaminergic medications for an extended length of time. It typically occurs in people with Parkinson’s disease (PD) who have taken dopamine agonist medications for an extended period of time.
Addiction like symptoms should be reported
What active drugs are in stalevo?
Levodopa with carbidopa and entacapone
What type of drug is amantadine?
It is a dopaminergic drug - dopamine receptor agonists
What is the MAO of amantadine?
Amantadine is a weak dopamine agonist with modest antiparkinsonian effects
Will switching between ergot and non-ergot derived doapmine receptor agonists control impulsive control disorders?
No it will not
What are the indications of bromocriptine?
- Prevention of lactation/ supression of lactation/ hypogonadism/ galactorrhoea/ infertility
prolactinoma
Parkinson’s disease
What is the MAO of bromocriptine?
It is a stimulant of dopamine receptors in the brain; it also inhibits release of prolactin by the pituitary.
What safety warning has been issued for bromocriptine use relating to fibrotic reactions?
It has been associated with pumonary retroperitoneal and pericardial fibrotic reactions.
Exclude supression of lactation
echocardiography before starting treatment
What advice should be given to patients that are on bromocriptine?
- Caution - provide contraceptive advice if appropriate (oral contraceptives may increase prolactin concentration)
Which drug has a similar action to bromocriptine?
- Cabergoline
Which dopamine agonist can be used for moderate to severe restless leg syndrome?
Pramipexole
Also used for parkinson’s disease
Give few more examples of dopamine receptor agonists used for Parkinson’s disease that have not yet been mentioned?
- Ropinirole
- Rotigotine
Give three examples of dopaminergic drugs that are classes as monoamine oxidase B inhibitors?
Rasagiline
Safinamide
Selegiline hydrochloride
Does the cause of vomiting need to be known before giving antiemetics?
Yes, Antiemetics are generally only prescribed when the cause of vomiting is known because otherwise, they may delay diagnosis, particularly in children.
Which antihistamines can be used for nausea and vomiting?
Cinnarizine
Cyclizine
Promethazine hydrochloride
Promethazine teoclate
Which three phenothiazines can be used for nausea?
- Chlorpromazine
- Prochlorperazine
- Trifluoperazine
How do phenothiazines (anti-psychotics) work to reduce nausea and vomiting?
- They are dopamine antagonists and act centrally by blocking the chemoreceptor trigger zone
What severe reaction can sometimes occur with phenothiazines especially in children?
- Severe dystonic reactions
Which phenothiazine can be used for chemotherapy-induced and radiation induced nausea and vomiting?
Prochlorperazine
- It is less sedating and available as a buccal tablet
Which two antipsychotics can be used in palliative care to relieve nausea and vomiting?
- Levomepromazine
- Haloperidol (unlicensed)
What does metoclopramide directly act on?
- acts directly on the gastric smooth muscle stimulating gastric emptying and it may be superior to the phenothiazines for emesis
Where does domepridone act and why is it more advantageous compared to metoclopramide and pehnothiazines?
- Acts at the chemoreceptor trigger zone
- It has the advantage over metoclopramide hydrochloride and the phenothiazines of being less likely to cause central effects, such as sedation and dystonic reactions, because it does not readily cross the blood-brain barrier.
Which anti-emetic is recommended in Parkinson’s disease?
- Low dose domperidone can be used to treat nausea caused by dopaminergic drugs
What are the 5HT3 - receptor antagonsits that can be used in the management and vomiting in patients receiving cytotoxic drugs?
- Granisetron
- Ondansetron
- Palonosetron
Which corticosteroid has antiemetic effects that can be used in the management of chemotherapy-induced nausea and vomiting?
Dexamethasone
Can be used alone or in combination with other antiemetics
Which neurokinin 1 receptor antagonists can be used to prevent nausea and vomiting associated with chemotherapy?
- Aprepitant
- Fosaprepitant
They are usually given in combination with dexamethasone and a 5HT3-receptor antagonist
Name a synthetic cannabioid with antiemetic properties?
Nabilone - It can be considered as an add on treatment for chemotherapy-induced nausea and vomiting unresponsive to optimised conventional antiemetics.
When should antiemetics be considered for pregnant women?
Antiemetics should be considered for women with persistent symptoms where self-care measures have been ineffective. If a non-pharmacological option is preferred, ginger may be helpful for mild to moderate nausea.
Which antiemetics can be used in pregnancy?
chlorpromazine hydrochloride, cyclizine, doxylamine with pyridoxine, metoclopramide hydrochloride, prochlorperazine, promethazine hydrochloride, promethazine teoclate, and ondansetron.
What does Hypermesis graviderum require?
Hyperemesis gravidarum is a more serious condition, which requires regular antiemetic therapy, intravenous fluid and electrolyte replacement, and sometimes nutritional support.
For women with severe or persistent hyperemesis gravidarum, antiemetics given by the parenteral or rectal routes may be more suitable than the oral route.
For women with persistent antiemetic use supplementation with which drug should be considered and why?
Supplementation with thiamine must be considered in order to reduce the risk of Wernicke’s encephalopathy.
what are the risk factors of postoperative nausea and vomiting?
depends on many factors including the anaesthetic used, and the type and duration of surgery. Other risk factors include female sex, younger age, non-smokers, a history of postoperative nausea and vomiting or motion sickness, and intraoperative and postoperative use of opioids.
With those with risk factors for postoperative nausea and vomiting is a combination of antiemetics recommended?
A combination of two or more antiemetic drugs that have different mechanisms of action is often indicated in those with risk factors for postoperative nausea and vomiting.
Which drugs are used in postop nausea and vomiting?
5 HT3 receptor antagonists (e.g. granisetron, ondansetron)
Dexamethasone droperidol hloperidol Cyclizine Prochlorperazine
What is cyclizine licensed for in post op?
Cyclizine is licensed for the prevention and treatment of postoperative nausea and vomiting caused by opioids and general anaesthetics.
What is prochlorperazine licensed for in post op?
For prevention and treatment of nausea and vomiting
Which drugs can be used for motion sickness?
Hyoscine hydrobromide
Antihistamines - cinnarizine, cyclizine
Promethazine,
Which antihistamines used for motion sickness is less sedative?
- Cinnarizine
- cyclizine
Which anithistamines used for motion sickness is more sedative?
- Promethazine
Which antiemetics are ineffective in motion sickness?
Domperidone, metoclopramide hydrochloride, 5HT3-receptor antagonists, and the phenothiazines (except promethazine—an antihistamine phenothiazine) are ineffective in motion sickness.
Patients presenting with Meniere’s Disease should be referred to who?
An ear, nose and throat (ENT) specialist to confirm the diagnosis.
Which histamine analgoue can be trialled to reduce the frequency and severity of hearing loss, tinnitus and vertigo in patient with recurrent attacks of Meniere’s Disease?
Betahistine
How many days should metoclopramide be limited to?
Should only be prescribed for short term use (up to 5 days)
What condition or characteristic as been associated with ondansetron use in babies where mothers used this drug?
small increased risk of cleft lip and/or cleft palate in babies born to women who used ondansetron during the first trimester.
is hyoscine butylbromide a antihistamine or a antimuscarinic drug?
Antimuscarinic
What are the two types which pain can be categorised into?
Nociceptive pain - which generally responds to treatment with conventional analgesics
- Neuropathic pain - responds poorly to conventional analgesics and can be difficult to treat
How many weeks is classed as chronic pain?
present for more than 12 weeks (beyond the expected time of wound healing).
What is the definition of chronic primary pain?
Chronic primary pain is defined as pain that has no clear underlying condition, or where the pain (or its impact) appears to be out of proportion to any observable injury or disease.
Give examples of chronic primary pain?
Types of chronic primary pain include complex regional pain syndrome, fibromyalgia (chronic widespread pain), primary headache and orofacial pain, primary visceral, and primary musculoskeletal pain.
what about secondary pain?
Secondary pain however, is caused by an underlying condition (such as endometriosis, osteoarthritis, rheumatoid arthritis, and ulcerative colitis) and can be organised into 6 pain categories:
What are the 6 categories of chronic secondary pain?
cancer-related, neuropathic, post-surgical or post-traumatic, secondary headache or orofacial, secondary musculoskeletal, and secondary visceral.
