Central Nervous System

Question 1

Name the 5 types of dementia

Answer 1

1. Alzheimer’s (50%)
2. Vascular dementia
3. Dementia with lewy bodies
4. Mixed dementia
5. Frontotemporal dementia

Question 2

Name the class of drugs and 3 examples within them that are used as first-line as monotherapy to treat mild-moderate Alzheimer’s?

Answer 2

Anticholineesterase inhibitors (AChEIs) as monotherapy are first-line treatment for mild-moderate Alzheimer’s. Three examples of AChEIs include:

1. Donepezil
2. Galantamine
3. Rivastigmine

Question 3

Which drug is described by the following?

1. I can be used as an alternative to AChEIs in patients with moderate Alzheimer’s
2. I can be used in addition to AChEIs in patients with moderate-to-severe Alzheimer’s
3. I am used as the first-line for severe Alzheimer’s

Answer 3

Memantine hydrochloride [NMDA Glutamine Receptor Antagonist]

Question 4

The following 3 questions relate to the treatment of mild-to-moderate dementia with Lewy bodies

1. Which 2 AChEIs can be used as first line treatment for mild-to-moderate dementia with Lewy bodies?
2. Which AChEI is used if these to are not tolerated?
3. Which drug is used if AChEIs are contra-indicated/not tolerated altogether?

Answer 4

1. Donepezil & Rivastigmine
2. Galantamine
3. Memantine

Question 5

Name the TWO classes of drugs used to treat vascular dementia in patients who have suspected co-morbid Alzheimer’s, Parkinson’s disease dementia, or dementia with Lewy bodies?

Answer 5

1. Acetylcholinesterase inhibitors

2. Memantine hydrochloride

Question 6

The following 2 questions relate to the management of frontotemporal dementia:

1. Which TWO drugs are NOT RECOMMENDED to treat frontotemporal dementia?
2. Is there a cure? If so, what is it? If not, what drugs are used for symptoms relief?

Answer 6

1. AChEIs & Memantine are NOT recommended to treat frontotemporal dementia
2. NO CURE — antidepressants or antipsychotics can be used to relieve symptoms

Question 7

Some commonly prescribed drugs are associated with anticholinergic burden and, therefore, cognitive impairment so their use should be minimised. The following drug classes cause antimuscarnic effects:

1. Antidepressants
2. Antihistamines
3. Antipsychotics
4. Urinary spasmodics

Name TWO drugs from each of these drug classes which cause antimuscarinic effects

Answer 7

Drugs that cause antimuscarinic effects include:

1. Antidepressants — Amitriptyline & Paroxetine
2. Antihistamines — Chlorphenamine & Promethazine
3. Antipsychotics — Olanzapine & Quetiapine
4. Urinary spasmodics — Solifenacin & Tolteradine

Question 8

Cholinergic side effects (parasymphatomimetic) can be memorised using the acronym: DUMB BELS.
What does each letter of this acronym stand for?

Answer 8

D — Diarrhoea
U — Urination
M — Muscle weakness, muscle cramps and miosis (pupil constriction)
B — Bronchospasm

B — Bradycardia
E — Emesis (vomiting)
L — Lacrimation (teary eyes)
S — Salivation/Sweating

Question 9

Below is a description of a disease-specific patient group:

Dementia patients who carry a risk of harming themselves or others, or experiencing severe non-cognitive symptoms (e.g., agitation, hallucinations or delusions) that cause severe distress.

The following 3 questions relate this this group:

1. Which drug class should be offered to such patients?
2. Which dose and duration should be offered?
3. How often should the patient be reviewed whilst on this class of medication?
4. Which 2 types of dementia should this medication be avoided as they worsen motor symptoms?

Answer 9

1. Antipsychotics
2. Lowest effective dose for the shortest time possible
3. Review every 6 weeks
4. Dementia with Lewy bodies or Parkinson’s disease dementia [Antipsychotics worsen motor symptoms]

Question 10

The following 2 questions relate to the MHRA advice regarding antipsychotics and dementia:

1. What is the MHRA Warning associated with the use of antipsychotics in elderly dementia patients?
2. What is the advice from the MHRA with regards to using antipsychotics in elderly dementia patients?

Answer 10

1. Increased risk of stroke & death when antipsychotics are used in elderly patients with dementia
2. The MHRA Advice is as follows:A) Risks and benefits should be assessed, including any previous history or stroke/TIA and any risk factors of cerebrovascular disease e.g., hypertension, diabetes, smoking & AFB) Use antipsychotics at the lowest possible dose for the shortest time and reviewed every 6 weeks.

Question 11

The following questions relate to the management of non-cognitive symptoms of dementia:

1. Name 2 drug classes used to treat extreme violence, aggression & agitation
2. Name 3 drugs used to treat these symptoms if I.M administration is needed for behavioural control

Answer 11

1. Benzodiazepines (Oral) or Antipsychotics

2. Haloperidol, Olanzapine & Lorazepam can be given I.M for behavioural control

Question 12

The following questions relate to antiepileptic dose frequency

1. How often are most antiepileptics given on a daily basis?
2. Which antiepileptics are given once daily?

Answer 12

1. Most antiepileptics are given twice daily (BD)
2. LP3 (LP = Long period) relates to antiepileptics which are given once a day and include:L - Lamotrigine
   P - Perampanel
   P - Phenobarbital
   P - Phenytoin

Question 13

What are the 2 MHRA Warnings for anti-epileptics

Answer 13

1. RISK OF SUICIDAL THOUGHTS & BEHAVIOUR! [1 week after starting]
2. DON’T SWITCH BRANDS for category 1 anti-epileptics
   [Epilepsy ONLY! Phenobarbital doesn’t need to be prescribed by brand if being used for bipolar]

Question 14

List the 4 anti-epileptics that cannot be switched between different brands due to an associated risk of hypersensitivity syndrome

Answer 14

CPR3

C - Carbamazepine [Tegretol, Carbagen (Retard and IR)]
P - Phenytoin [Epanutin]
P - Phenobarbital
P - Primidone

Question 15

List the category of which the following anti-epileptics are classified

1. Valproate, Lamotrigine, Topiramate, Clobazam (SLS for epilepsy) & Clonazepam
2. Levetiracetam, Brivaracetam, Ethosuximide, Vigabatrin, Tiagabine, Gabapentin & Pregabalin

Answer 15

1. Category 2

2. Category 3

Question 16

List the 8 anti-epileptics which are associated with anti-epileptic hypersensitivity syndrome

Answer 16

Carbamazepine, Phenobarbital, Phenytoin, Primidone (CPR3), Rufinamide, Lamotrigine, Lacosamide & Oxcarbazepine

Question 17

The following questions relate to anti-epileptic hypersensitivity syndrome

1. List the 3 main symptoms of anti-epileptic hypersensitivity syndrome
2. What period of time do the symptoms usually start between?
3. What action should be taken if a patient experiences the symptoms?

Answer 17

1. Fever, rash, & lymphadenopathy (swollen or enlarged lymph nodes)
2. 1-8 weeks after starting [monitor in first 2 weeks]
3. Withdrawal immediately

Question 18

The following questions relate to the withdrawal of anti-epileptics

1. Which 2 classes of anti-epileptics carry the risk of rebound seizures & how long should they be withdrawn?
2. How many drugs can be withdrawal at one given time?
3. List the following for other anti-epileptics: withdrawal duration, daily dose reduction (%) and frequency

Answer 18

1. Benzodiazepines (>6 months) and Barbiturates (months)
2. ONE
3. Withdraw gradually over 2-3 months by reducing daily dose by 10-25% every 1-2 weeks

Question 19

You are a pharmacist at a GP practice. There are 2 patients in your room. The first one has had their first unprovoked epileptic seizure and the other has had a single isolated seizure. What advice will you will give to them regarding their driving?

A) You must not drive for 12 months; you may drive if deemed fit to by a specialist as fit undergone investigations which do not suggest a risk of further seizures

B) You must not drive for 9 months; you may drive if deemed fit to by a specialist as fit undergone investigations which do not suggest a risk of further seizures

C) You must not drive for 6 months; you may drive if deemed fit to by a specialist as fit undergone investigations which do not suggest a risk of further seizures

Answer 19

C) Patients 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.

Question 20

How long does a patient with established epilepsy need to be seizure-free for and what other criteria applies to this, if any?

Answer 20

1 year for established epilepsy patients for the following:

1. Seizure-free for 1 year
2. Established seizure pattern for 1 year where no influence on consciousness or ability to act
3. No history of unprovoked seizures
4. 1 year wait in those who have had a seizure due to a prescribed change/withdrawal (earlier if treatment reinstated for 6 months & no further seizures)
5. Seizure whilst asleep [2 exceptions]

Question 21

You are working remotely as a PCN pharmacist for a GP surgery. On your calls list today is an epilepsy patient who would like to to discuss the possibility of driving. You see on their PMR that they have a history of seizures whilst asleep.

What are the 2 exceptions that would make it permissible for this patient to drive despite having seizures whilst asleep?

Answer 21

1. History of no awake seizures for 1 year from the first sleep seizure
2. If previous awake seizure — established pattern of sleep seizures for 3 years

Question 22

List the 3 main recommendations the DVLA have made to ban driving for epilepsy patients.

Answer 22

Driving is banned for the following:

1. During medication changes or withdrawal
2. 6 months after last dose
3. 6 months for first unprovoked epileptic seizure or single isolated seizure (5 years for large goods or taxi)

Question 23

Fill in the gaps for the statement below.

A pregnant woman who suffers from epilepsy is at an increased risk of ………….. especially in the ….. trimester and particularly if the patient is taking ……… anti-epileptic drugs.

Answer 23

1. Teratogenicity
2. First
3. Two or more

Question 24

Name 5 anti-epileptics that require dose adjustments in pregnancy?

Answer 24

CPR3 & Lamotrigine

1. Carbamazepine
2. Phenobarbital
3. Phenytoin
4. Primidone
5. Lamotrigine

Question 25

Which anti-epileptic is associated with an increased risk of cleft palate during the 1st trimester of pregnancy?

Answer 25

Topiramate = cleft palate

Question 26

Name 2 anti-epileptics that require monitoring of foetal growth

Answer 26

1. Topiramate | 2. Levetiracetam

Question 27

What injection is administered to newborn babies to minimise the risk of neonatal haemorrhage?

Answer 27

Vitamine K injection

Question 28

Drug X is given to women taking anti-epileptic medication as it reduces the risk of neural tube defects. State the name of Drug X and the duration in which it should be taken for

Answer 28

Folic Acid 5mg daily: 1. Before conception 2. During 1st trimester

Question 29

The following questions relate to anti-epileptics and breastfeeding 1. Which 4 anti-epileptics are present in high amounts of milk when breastfeeding? 2. Which 2 anti-epileptics accumulate due to slower metabolism in infants?

Answer 29

1. ZELP - (Zonisamide, Ethosuximide, Lamotrigine, Primidone) | 2. Phenobarbital and Lamotrigine

Question 30

Drug X and Drug Y are anti-epileptics with the following features: 1. Both inhibit the sucking reflex when breastfeeding 2. Avoid abrupt withdrawal of breastfeeding both drugs State the names of Drug X and Drug Y

Answer 30

1. Phenobarbital | 2. Primidone

Question 31

Name 3 anti-epileptics that are associated with a risk of drowsiness in babies?

Answer 31

1. Phenobarbital 2. Primidone 3. Benzodiazepines

Question 32

Name the 2 anti-epileptics which are used as first-line to treat focal (partial) seizures with or without secondary generalisation

Answer 32

1. Carbamazepine 2. Lamotrigine Memory Trick [fo-C-A-L] C - Carbamazepine A - AND L - Lamotrigine

Question 33

Name 3 alternative anti-epileptics used to treat focal (partial) seizures with or without secondary generalisation

Answer 33

1. Oxcarbazepine 2. Sodium Valproate 3. Levetiracetam

Question 34

Name the 4 different types of generalised seizures

Answer 34

1. Tonic-clonic seizures 2. Absence seizures 3. Myoclonic seizures 4. Atonic & Tonic seizures

Question 35

Which type of generalised seizure is described as the following: 1. Whole-body stiffness 2. Loss of consciousness 3. Body shakes (convulsions) due to uncontrollable muscle contractions 4. Loss of bladder/bowel motions, biting of tongue/cheek & difficulty breathing

Answer 35

Tonic-clonic seizure Memory Trick: T for Tonic = T for tightness (stiffness) C for Clonic = C for convulsions/contraction

Question 36

Which type of generalised seizure is described as the following: 1. Brief loss of consciousness and awareness for a few seconds 2. NO convulsion and NO fall over 3. Children mainly

Answer 36

Absence Seizure

Question 37

Which type of generalised seizure is described as a sudden muscle contraction (jerk affecting the whole body but often in 1/2 arms)

Answer 37

Myoclonic seizure

Question 38

Which type of generalised seizure is described as the following: 1. Brief loss of consciousness 2. Stiffness 3. Fall to the ground

Answer 38

Atonic & Tonic Seizure

Question 39

Name the anti-epileptic which is the first-line treatment for all generalised seizures

Answer 39

Sodium Valproate

Question 40

Answer the following questions regarding tonic-clonic seizures 1. First-line treatment (3 drugs) 2. First-line treatment in pre-menopausal women (1 drug) 3. Alternative treatment (1 drug)

Answer 40

1. First-line for tonic-clonic = Valproate, Carbamazepine, Oxcarbazepine 2. First-line for tonic-clonic in pre-menopausal women = Lamotrigine 3. Alternative for tonic-clonic = Lamotrigine

Question 41

Answer the following questions regarding absence seizures: 1. First-line treatment (2 drugs) 2. Alternative treatment (1 drug)

Answer 41

1. First-line for absence seizures = Ethosuximide or Valproate (if there's a high risk of generalised tonic-clonic seizure) 2. Alternative treatment for myoclonic seizures = Lamotrigine Memory Trick: SEAL = Sodium valproate or Ethosuximide. Alternatively, Lamotrigine

Question 42

Answer the following questions regarding myoclonic seizures: 1. First-line treatment (1 drug) 2. Alternative treatment (2 drugs)

Answer 42

1. First-line for myoclonic seizures = Sodium Valproate 2. Alternative for myoclonic seizures = Levetiracetam & Topiramate Memory Trick: SALT = Sodium Valproate. Alternatively, Levetiracetam, Topiramate

Question 43

Answer the following questions regarding atonic & tonic seizures: 1. First-line treatment (1 drug) 2. Adjunctive treatment (1 drug) 3. Alternative treatment (2 drugs)

Answer 43

1. First-line for atonic & tonic = Sodium Valproate 2. Adjunctive for atonic & tonic = Lamotrigine 3. Alternative for atonic & tonic = Rufinamide or Topiramate Memory Trick: SLART = Sodium Valproate, Lamotrigine. Alternatively, Rufinamide, Topiramate

Question 44

Name the 3 types of generalised seizures that Carbamazepine or Oxcarbazepine is not recommended for?

Answer 44

1. Absence 2. Mycolonic 3. Atonic & Tonic

Question 45

What is the optimum plasma concentration for Carbamazepine in mg/L and micromol/L and how long after initiation should these levels be measured?

Answer 45

Optimum plasma concentration of Carbamazepine is 4-12mg/L (20-50 micromol/L). Measure after 1-2 weeks.

Question 46

Which anti-epileptic are the following symptoms indicative of? Hyponatraemia, Ataxia, Nystagmus, Drowsiness, Blurred vision, Arrhythmias & G.I [N&V] ``` A) Lamotrigine B) Sodium Valproate C) Carbamazepine D) Topiramate E) Ethosuximide ```

Answer 46

D) Carbamazepine Think: HAND BAD [Hyponatraemia, Ataxia, Nystagmus, Drowsiness, Blurred vision, Arrhythmias & G.I [N&V]]

Question 47

Which anti-epileptic is associated with skin reactions such as Steven-Johnson syndrome (SJS) & toxic epidermal necrolysis and there is a higher risk of a rapid dose increase when given with Valproate?

Answer 47

Lamotrigine

Question 48

Which of the following anti-epileptics is NOT associated with blood dyscrasias where reports of infection, bruising or bleeding must be reported? ``` A) Valproate B) Ethosuximide C) Carbamazepine D) Phenytoin E) Zonisamide F) Lacosamide G) Lamotrigine H) Topiramate ```

Answer 48

F) Lacosamide Explanation: Think “C Vet Plz” ``` C - Carbamazepine V - Valproate E - Ethosuximide T - Topiramate P - Phenytoin L - Lamotrigine Z - Zonisamide ```

Question 49

Which anti-epileptic is associated with visual field defects? ``` A) Lamotrigine B) Valproate C) Carbamazepine D) Vigabatrin E) Topiramate ```

Answer 49

D) Vigabatrin Think Vi for Vigabatrin and Vi for Visual

Question 50

Which anti-epileptic is associated with acute myopia with secondary angle-closure glaucoma and choroidal effusions and anterior displacement of lens and iris? ``` A) Lamotrigine B) Valproate C) Carbamazepine D) Vigabatrin E) Topiramate ```

Answer 50

E) Topiramate

Question 51

Which anti-epileptic is associated with encephalopathic symptoms such as marked sedation, stupor, and confusion with non-specific slow wave ECG where the dose should be withdrawn or reduced. ``` A) Lamotrigine B) Valproate C) Carbamazepine D) Vigabatrin E) Topiramate ```

Answer 51

D) Vigabatrin

Question 52

The following questions relate to Gabapentin and Pregabalin: 1) Which type of seizures are Gabapentin and Pregabalin licensed to treat? 2) Which other indication is Pregabalin licensed for aside from this and treating neuropathic pain?

Answer 52

1) Focal seizures with or without secondary generalisation | 2) Generalised anxiety disorder

Question 53

What is the MHRA Warning for Gabapentin (Neurontin) and list the 4 patient groups at higher risk

Answer 53

MHRA Warning for Gabapentin (Neurontin) = Severe respiratory depression Patients at higher risk include: 1) Compromised respiratory function 2) Respiratory/neurological disease 3) Eldery 4) Renal impairment (Gabapentin is really cleared)

Question 54

Which anti-epileptic is an enzyme inhibitor which therefore, increases plasma concentration (Cp)? A) Phenytoin B) Carbamazepine C) Valproate D) Phenobarbital

Answer 54

C) Valproate The others (Carbamazepine, Phenytoin and Phenobarbital) are all enzyme inducers (decrease Cp)

Question 55

Name the two types of seizures that Phenytoin is used for and 2 that it must be avoided for

Answer 55

Phenytoin is indicated for focal seizures and tonic-clonic seizures Phenytoin must be avoided in absence and myoclonic seizures

Question 56

Phenytoin is known as a high-risk drug with a narrow therapeutic index. What is the therapeutic range for Phenytoin? ``` A) 4-12 mg/L B) 10-20 mg/L C) 5-10 mg/L D) 0.4-1 mmol/L E) 5-10 mg/L ``` (Bonus point if you name the therapeutic range for neonate <3m)

Answer 56

B) 10-20 mg/L (40-80 micromol/L) | Neonate <3m have a therapeutic range of 6-15mg/L or 25-50micromol/L

Question 57

Which narrow therapeutic index drug are the following symptoms of toxicity associated with? Nystagmus, Hyperglycaemia, Diplopia (double vision), Confusion, Slurred speech & Ataxia (co-ordination, balance & speech issues) ``` A) Gentamycin B) Theophylline C) Carbamazepine D) Phenytoin E) Digoxin F) Lithium ```

Answer 57

D) Phenytoin Signs & symptoms of toxicity in Phenytoin - Think “SNAtCHeD” S - Slurred speech N - Nystagmus (uncontrolled repetitive eye movements e.g., eye rolling) A - Ataxia (lack of voluntary co-ordination of muscle of movement) C - Confusion H - Hyperglycaemia D - Diplopia (double vision), BLURRED VISION

Question 58

Which vitamin should be given to patients on Phenytoin and Valproate?

Answer 58

Vitamin D (pts immobilised for long periods or inadequate sun exposure/ inadequate calcium intake)

Question 59

Which form of administration should be avoided in Phenytoin due to slow and erratic absorption? ``` A) Tablets B) Intravenous C) Intramuscular injection D) Capsules E) Oral Suspension ```

Answer 59

C) Intramuscular injection

Question 60

Which of the following anti-epileptics is associated with side effects including bradycardia and hypotension (I.V. Only), acne, hirsute symptoms, gingival hypertrophy, nystagmus, blood dyscrasias (antifolate), osteopenia, neuropathy and teratogenicity? ``` A) Topiramate B) Phenobarbital C) Carbamazepine D) Valproate E) Phenytoin ```

Answer 60

E) Phenytoin

Question 61

How long does convulsive status epilepticus last? ``` A) >2 mins B) >3 mins C) >4 mins D) >5 mins E) >6 mins ```

Answer 61

D) >5 mins (or occur seizures occur one after the other with no recovery)

Question 62

The following questions relate to convulsive status epilepticus: 1) What medication should be administered to patient where alcohol is suspected? 2) First-line in hospital? 3) First-line when not in hospital?

Answer 62

1) I.V Thiamine 2) I.V Lorazepam 3) Diazepam rectal or Midazolam buccal

Question 63

Which of the following is not an example of a long-acting benzodiazepine? ``` A) Alprazolam B) Clobazam C) Chlordiazepoxide D) Diazepam E) Midazolam ```

Answer 63

E) Midazolam (SA benzodiazepine)

Question 64

Which of the following is not an example of a short-acting benzodiazepine? ``` A) Midazolam B) Tempazem C) Loprazolam D) Alprazolam E) Lometazepam ```

Answer 64

D) Alprazolam (LA benzodiazepine)

Question 65

Name 2 different drugs which you may consider prescribing to help managing anxiety before a dental procedure.

Answer 65

Temazepam or Diazepam

Question 66

Which hormone is licensed for the short-term treatment of insomnia and jet lag for a 57-year-old patient?

Answer 66

Melatonin (pineal hormone)

Question 67

Drug X has the following features: - Acts at specific serotonin (5HT1A) receptors (agonist) - Used for short-term anxiety - Response to treatment may take up to 2 weeks - Does not alleviate symptoms of benzodiazepine withdrawal, so benzodiazepines should still be withdrawn slowly before starting Drug X What is the name of Drug X?

Answer 67

Buspirone

Question 68

Which very short-acting barbiturate is used in anaesthesia?

Answer 68

Thiopental

Question 69

Which class of drugs can be used in the treatment of anxiety that treats autonomic symptoms (e.g., palpitations and tremors) but does not affect psychological symptoms (worry, fear, tension)?

Answer 69

Beta blockers such as Propranolol or Oxprenolol (help reduce BP which help reduce autonomic symptoms but do not treat psychological symptoms)

Question 70

For short-term users of benzodiazepines, what is the duration for withdrawal of this class of drug? ``` A) 1-2 weeks B) 2-4 weeks C) 4-6 weeks D) 6-8 weeks E) Several months ```

Answer 70

B) 2-4 weeks

Question 71

With regards to the protocol for withdrawal of long-term benzodiazepines, what is the correct diazepam withdrawal dose and duration? ``` A) 1-2mg every 1-2 weeks B) 2-4mg every 2-4 weeks C) 1-2mg every 2-4 weeks D) 2-4mg every 1-2 weeks E) 1-2mg every 3-5 weeks ``` Bonus Q: If necessary, what increment can Diazepam be reduced to further until completely stopped?

Answer 71

C) 1-2mg every 2-4 weeks. Can reduce Diazepam further if needed in smaller steps of 500mcg towards the end. Then completely stop

Question 72

Name 2 benzodiazepines that can be administered parenterally to treat panic attacks

Answer 72

1. Diazepam | 2. Lorazepam

Question 73

Name 3 cautions with benzodiazepines (instances where they should be avoided)

Answer 73

1. Avoid prolonged use 2. Avoid abrupt withdrawal 3. Avoid in pts with a history of drug/alcohol dependence

Question 74

Which of the following is not a contraindication of benzodiazepines? ``` A) Sleep apnoea syndrome B) Unstable myasthenia gravis C) Renal impairment D) Acute pulmonary insufficiency E) Neuromuscular respiratory weakness ```

Answer 74

C) Renal impairment

Question 75

Which of the following benzodiazepines is associated with the precipitation of a coma? ``` A) Oxazepam B) Midazolam C) Loprazolam D) Alprazolam E) Lormetazepam F) Diazepam G) Temazepam ```

Answer 75

F) Diazepam SA Benzodiazepines are the safest. ``` Memory trick for SA benzo's = MO is TALL M - Midazolam O - Oxazepam T - Temazepam A - Alprazolam L - Loprazolam L - Lormetazepam ```

Question 76

Name 2 drugs that are recommended as first-line treatment for ADHD

Answer 76

1. Lisdexamfetamine | 2. Methylphenidate

Question 77

Name 2 drugs that are used as alternatives to Methylphenidate for the treatment of ADHD?

Answer 77

1. Atomoxetine | 2. Dexamfetamine

Question 78

Mr Blackburn has been newly diagnosed with ADHD. His drug history on his PMR states that he regularly attends your pharmacy to collect daily supervised Methadone as he has a history of drug misuse. Which ADHD drug would you expect to see on his new prescription? ``` A) Lisdexamfetamine B) Methylphenidate C) Dexamfetamine D) Atomoxetine E) Guanfacine ```

Answer 78

D) Atomoxetine

Question 79

Mrs Smith has been newly prescribed Methylphenidate for her ADHD? What 2 pieces of counselling would you provide her upon handing over her prescription?

Answer 79

1. Affects driving | 2. Effects increased by alcohol

Question 80

The side effect profile of Drug X in the initial months of treatment or after a dose change is as follows (agitation, irritability, suicidal thoughts, self-harming, unusual behaviour changes). Which of the following ADHD medications is Drug X? ``` A) Lisdexamfetamine B) Methylphenidate C) Dexamfetamine D) Atomoxetine E) Guanfacine ```

Answer 80

D) Atomoxetine

Question 81

Name 5 drugs/drug classes used in the management of bipolar

Answer 81

1. Lithium 2. Valproate 3. Carbamazepine 4. Antipsychotics 5. Benzodiazepines

Question 82

The following 2 questions relate to mania and hypomania: 1. How long does drug treatment for bipolar last from the last manic episode? 2. How long does drug treatment for bipolar last if the patient has risk factors for relapse?

Answer 82

1. Two years at least | 2. Up to five years

Question 83

Which drug class should be avoided in patients with established rapid cycling bipolar disorder, hypomania, or rapid mood fluctuations?

Answer 83

Antidepressants

Question 84

The following questions relate to antipsychotics in mania & hypomania: 1. Name 3 antipsychotics that are recommended for mania and hypomania 2. If the response is inadequate, which 2 drugs can be considered as an add-on therapy to an antipsychotic?

Answer 84

1. Olanzapine, Quetiapine & Risperidone | 2. Lithium or Valproate

Question 85

Mr H suffers from mania and hypomania and is currently taking Risperidone and Olanzapine. His doctor wishes to discontinue the Olanzapine but is unsure of the duration in which this needs to be achieved? What do you advise him? ``` A) Gradually discontinue >2 weeks B) Gradually discontinue >3 weeks C) Gradually discontinue >4 weeks D) Gradually discontinue >5 weeks B) Gradually discontinue > 6 weeks ```

Answer 85

C) Gradually discontinue over 4 weeks Since the patient is taking more than one antimanic drug, the duration of discontinuation should be over 4 weeks

Question 86

The following two patients from mania and hypomania wish to discontinue their antipsychotics 1. Mrs F taking Quetiapine 2. Mr E taking Risperidone who has a history of relapse What duration of discontinuation would you advise their GPs when considering this? ``` A) >2 weeks B) >4 weeks C) >6 weeks D) >8 weeks E) >12 weeks ```

Answer 86

E) >12 weeks = >3 months which is the duration of discontinuation of an antipsychotic for patients on a single antipsychotic or if there is a history of relapse

Question 87

What drug is used for the prophylaxis of bipolar disorder (manic depressive disorder) and for patients with rapid cycling manic depressive illness who have had 4 or more episodes per year?

Answer 87

Carbamazepine

Question 88

What drug is used for the treatment and prophylaxis of manic episodes of bipolar which should be avoided in women of childbearing age?

Answer 88

Valproate

Question 89

Which drug is used in the prophylaxis & treatment of mania, hypomania and depression in bipolar disorder (manic-depressive disorder) and also used to treat aggressive or self-harming behaviour?

Answer 89

Lithium salts

Question 90

# Fill in the blank The full prophylactic effect of Lithium may not occur for ____ after initiation of therapy ``` A) 2-3 months B) 4-6 months C) 4-8 months D) 6-12 months E) 8-12 months ```

Answer 90

D) 6-12 months

Question 91

Which of the following is not a contraindication of Lithium? ``` A) Dehydration B) Untreated hypothyroidism C) Significant renal impairment D) Hypernatraemia/ high Na+ diets E) Addison's disease ```

Answer 91

D) Hypernatraemia/ high Na+ diets Lithium conc must be increased in low sodium diets Dehydration increases the S/E of Lithium. Lithium affects T4 production and can cause hypothyroidism Lithium is CI in severe renal impairment, Addison's disease and cardiac disease

Question 92

Which of the following is not an interaction associated with Lithium? ``` A) QT interval prolongation B) Hypokalaemia C) CCBs D) ACE-I E) NSAIDs ```

Answer 92

C) CCBs do not interact with Lithium Lithium + drugs causing QT prolongation increases risk Diuretics/Corticosteroids + Lithium can cause hypokalaemia ACE-I & NSAIDs may increase Lithium levels

Question 93

Name each letter of the 'LITHIUMS' S/E mnemonic

Answer 93

L - Levels (0.4-1mmol/L = lower range for maintenance & elderly; 0.8-1mmol/L = acute episodes of mania & pts who prev relapsed) I - Increased urination (polyuria) T - Tremour, thirst & teratogenic [Avoid in 1st trimester] H - Hypothyroidism [weight gain/fatigue] I - Interactions [NSAIDs/ACE-I/ARBs/Diuretics/Antacids] U - Upset stomach [Diarrhoea, N&V] M - Muscle weakness S - Skin effects [acne, psoriasis]

Question 94

Dr S is commencing treatment of Priadel 200mg tablets (One To Be Taken Daily) for one of your patients and has booked the pt in to get their bloods done to assess before commencing this medication. He asks you to order bloods for this pt. Name the 6 investigations that you will request for?

Answer 94

1. Cardiac function 2. Thyroid function 3. Renal function 4. U&Es 5. FBC 6. BMI

Question 95

Which statement regarding routine serum-lithium conc monitoring is correct? A) Perform before initiation and after each dose change until stable, then monitor every 3m B) Perform before initiation and after each dose change until stable, then monitor every 6m C) Perform weekly after initiation and after each dose change until stable, then monitor every 3m D) Perform weekly initiation and after each dose change until stable, then monitor every 6m E) Perform 2 weeks after initiation and after each dose change until stable, then monitor every 3m

Answer 95

C) Perform weekly after initiation and after each dose change until stable, then monitor every 3m

Question 96

Which of the following regarding treatment cessation of Lithium is correct? A) Reduce gradually over a period of 1 week - 3 months B) Reduce gradually over a period of 2 weeks - 2 months C) Reduce abruptly D) Reduce gradually over a period of 4 weeks - 3 months E) Reduce gradually over a period of 4 weeks - 2 months

Answer 96

D) Reduce gradually over a period of 4 weeks - 3 months

Question 97

Name the letters in the 'LAND on the MAT' mneomic regarding Lithium drug interactions

Answer 97

L - Lithium interacts with: A - ACE-I/ARBs N - NSAIDs D - Diuretics M - Metronidazole A - Amiodarone T - Tetracyclines

Question 98

Which of the following does not decrease Lithium concentration? A) Theophylline B) Ramipril C) Osmotic & carbonic anhydrase inhibitor diuretics D) Urinary alkalising agents for cystitis E) Na+ containing antacids soluble analgaesics

Answer 98

B) Ramipril

Question 99

Which of the following does not increase neurotoxicity with Lithium? ``` A) Carbamazepine B) Amlodipine C) Sertraline D) Sumatriptan E) Verapamil F) Tramadol G) Citalopram H) Quetiapine ```

Answer 99

F) Tramadol Drugs that increase neurotoxicity with Lithium include: - Carbamazepine - Antipsychotics - SSRIs - Triptans - CCBs - Drugs causing hypokalaemia prolong QT interal with Lithium [e.g., diuretics, corticosteroids, B agonists]

Question 100

Which of the following does not increase the risk of serotonin syndrome with Lithium? ``` A) Citalopram B) Tramadol C) Sumatriptan D) St Johns Wort E) Amitriptyline F) Rasagiline ```

Answer 100

E) Amitriptyline Drugs which increase the risk of serotonin syndrome with Lithium include: - SSRIs - MOAIs (Rasagiline) - St John's Wort - Triptans - Tramadol

Question 101

Name the 3 major classes of antidepressants and one other class

Answer 101

1. SSRIs [Increase 5HT, NA levels] 2. TCAs [Increase 5HT only] 3. MAOIs [Increase 5HT, NA and Dopamine] 4. Other = SNRIs [e.g., Venlafaxine & Duloxetine]

Question 102

Match the TCAs with their description 1. Amitriptyline & Nortriptyline 2. Dosulepin 3. Imipramine 4. Lofepramine A) Liver toxic [hepatotoxicity] B) Most antimuscarinic TCA C) Used for neuropathic pain D) Dangerous in overdose - specialist use only

Answer 102

1) C Amitriptyline & Nortriptyline can also be used for neuropathic pain 2) D Dosulepin is dangerous in overdose - specialist use only 3) B Imipramine is the most antimuscarinic TCA 4) A Lofepramine [Liver toxic] - L = Liver

Question 103

Give 2 examples of tetracyclic antidepressants

Answer 103

1. Trazodone | 2. Manserin

Question 104

Match the SSRIs with their description 1. Citalopram/Escitalopram 2. Fluoxetine 3. Sertraline 4. Paroxetine A) Licensed in children from 5 yrs B) High withdrawal symptoms C) Safe to use after M.I/ unstable angina D) QT prolongation

Answer 104

1) D Citalopram/Escitalopram is associated with QT prolongation 2) A Fluoxetine is licensed in children aged 5-7 [unlicensed] risk of self-harm 3) C Sertraline is safe to use after M.I/ unstable angina 4) B Paroxetine is associated with high withdrawal symptoms

Question 105

Match the MAO-Is with their description 1. Phenelzine/Isocarboxazid 2. Tranylcypromine 3. Moclobemide A) Reversible Inhibitor (RIMA) used for social anxiety disorder, requiring no washout period B) Hepatotoxicity risk C) Hypertensive crisis risk

Answer 105

1) B Phenelzine/Isocarboxazid are associated with a greater hepatotoxicity risk 2) C Tranylcypromine is associated with a greater hypertensive crisis risk 3) A Moclobemide is a RIMA which can be used for social anxiety disorder and requires no washout period

Question 106

The following questions relate to antidepressant indications 1. Which form of depression are antidepressants effective for? 2. How long does it take for antidepressants to work? 3) How long should treatment be continued for before switching due to lack of efficacy in (i) adults and (ii) elderly? 4. What is the first noticable benefit of drug therapy? 5. What does paradoxical effects of antidepressants mean?

Answer 106

1) Moderate-to-severe as CBT is 1st line for mild depression 2) 2 weeks 3) Continue treatment for (i) 4 weeks for adults (ii) 6 weeks for elderly 4) Sleep improvement 5) There is an increased potential for agitation, anxiety & suicidal thoughts during the first few weeks of drug treatment (paradoxical effects)

Question 107

Name the antidepressant class which is the 1st line for moderate-to-severe depression and 3 reasons why

Answer 107

SSRIs 1. Better tolerated & safer in overdose 2. Less sedating 3. Fewer antimuscarinic & cardiotoxic effects

Question 108

Match the length of treatment with description of the patient 1. Mr H (47) has a history of recurrent depression and is currently taking Sertraline 100mg OD for maintenance 2. Mr Q (35) who has recently been prescribed Citalopram 10mg OD following a remission 3. Miss M (19) who takes Venlafaxine 75mg OD for generalised anxiety disorder 4. Mrs ZK (86) who takes Citalopram 10mg OD following a remission A) At least 6 months B) At least 12 months C) At least 2 years D) 12 months

Answer 108

1) C 2) A 3) D 4) B

Question 109

Which of the following is associated with all classes of antidepressants (esp SSRIs)? ``` A) Hyperkalaemia B) Hypernatraemia C) Hypocalcaemia D) Hyponatraemia E) Hypokalaemia F) Hypermagnesiemia G) Hypercalcaemia H) Hypomagnesiemia ```

Answer 109

D) Hyponatraemia Hyponatraemia (salt loss) is associated with ALL types of antidepressants (esp in elderly) - occurs more with SSRIs

Question 110

Name the words of the 'SALT LOSS' mneomnic for the signs of hyponatraemia

Answer 110

S - Stupor/coma A - Anorexia L - Lethargy T - Tendon reflexes (decreased) L - Limp muscles (weakness) O - Orthostatic hypotension S - Seziures/headaches S - Stomach cramps

Question 111

Name 6 symptoms of serotonin syndrome | Hint: Serotonin syndrome makes chemists doubly annoyed

Answer 111

1. Sweating 2. Shivering 3. Muscle twitching 4. Confusion 5. Diarrhoea 6. Agitation

Question 112

Name 6 drugs which cause serotonin syndrome when taken concomitantly (Hint: Many Lovely Therapists Like Serotonin Syndrome)

Answer 112

1. MAOIs 2. Lithium 3. Triptans 4. Lisdexamfetamine 5. St John's Wort 6. SSRIs

Question 113

You are a PCN pharmacist conducting a medication review on a patient taking Sertraline 50mg OD. They have failed to respond to this treatment. What are the three options you could provide for this patient?

Answer 113

1. Increase dose to 100mg OD 2. Switch to a different SSRI (e.g., Citalopram 10mg OD) 3. Initiate Mirtazapine 15mg ON

Question 114

Which antidepressant can be considered as a second line choice reserved for severe cases of depression?

Answer 114

Venlafaxine

Question 115

Name 3 antidepressants which can be used as second line treatment for depression

Answer 115

1. Lofepramine (TCA) 2. Reboxetine 3. Moclobemide (reversible MAOI)

Question 116

Name 3 third line options for depression

Answer 116

1. Add another antidepressant class 2. Add Lithium 3. Add an antipsychotic

Question 117

Which of the following is not considered as a less sedating TCA? A) Nortriptyline B) Imipramine C) Amitriptyline D) Lofepramine

Answer 117

C) Amitriptyline Mnemonic for sedating TCAs (No Lie In) No - N = Nortiptyline Lie - L = Lofepramine In - I = Imipramine Sedating TCAs are given to withdrawn & apathetic patients

Question 118

List 6 TCAs with sedating properties that are used for agitated & anxious patients (HINT: Amitriptyline Can Triple The Daytime Drowsiness)

Answer 118

1. Amitriptyline 2. Clomipramine 3. Trazodone 4. Trimipramine 5. Dosulepin 6. Dozepin

Question 119

Name each word relating to the 'TCAS' mnemonic for the S/E of TCAs

Answer 119

T - More toxic in overdose than SSRIs C - Cardiac S/E [QT prolongation, heart block, hypertension, arrhythmia etc] A - Antimuscarinic S/E S - Seizures

Question 120

What are the ABCD'S of antimuscarinic/anticholinergic S/E?

Answer 120

``` A - Anorexia B - Blurry vision C - Constipation/confusion D - Dry mouth S - Static urine ```

Question 121

What is the PS3 mnemonic for anticholinergic/antimuscarinic S/E?

Answer 121

- Can't Pee - Can't See - Can't Spit - Can't Shit

Question 122

What drug increases the risk of neurotoxicity when given alongside a TCA?

Answer 122

Lithium

Question 123

# Fill in the blank. There is a risk of severe toxicity with TCAs when given with ___ ``` A) SSRIs B) MAOIs C) SNRIs D) Tetracyclic antidepressants E) Antipsychotics ```

Answer 123

B) MAOIs

Question 124

Which of the following drugs when given alongside a TCA increases the risk of arrhythmias? ``` A) Lithium B) Citalopram C) Phenylephrine D) Amiodarone E) Carbamazepine ```

Answer 124

C) Phenylephrine

Question 125

Explain the memory trick for MAOI = MAOOI

Answer 125

M - Massive hypertension crisis risk [massive headache] A - Avoid tyramine [triggers hypertension crisis] - stroke/M.I O - OTC meds [symphatomimetics/adrenaline etc] O - Other antidepressants [MOAIs DON'T MIX with others] - causes serotonin syndrome I - Increased suicide risk

Question 126

You are a prescribing pharmacist and a 76-year-old who is currently taking Isocarboxacid 10mg daily for depression informs you that she has been experiencing frequent headaches. Which of the following is the most appropriate action to take? A) Reduce her to 5mg daily B) Advise her to take paracetamol for a few days and come back if headache still occurs C) Prescribe Sumatriptan D) Discontinue this, taper down slowly and consider a different antidepressant E) Tell her it will resolve itself after a few days

Answer 126

D) Discontinue this, taper down slowly and consider a different antidepressant

Question 127

What is the washout period for the following when switching to and from an MAOI 1. Clomipramine/Imipramine 2. SSRIs 3. TCA 4. Fluoxetine 5. Other MAOIs [Not RIMA] 6. Other antidepressants

Answer 127

1. 3 weeks 2. 1 week 3. 1-2 weeks 4. 5 weeks 5. 2 weeks [0 for Moclobemide] 6. 2 weeks

Question 128

# Fill in the blanks The following foods contain a natural compound called (i) _____ which interacts with MAOIs and interactions exist (ii) ___ weeks after stopping an irreversible MAOI Mature cheese, wine, pickled herring, broad bean pods, meat stocks, Bovril, OXO, Marmite [or similar meat/yeast extract], fermented soya bean extract, game meat [rabbit, pheasant, duck]

Answer 128

(i) Tyramine | (ii) Two

Question 129

Which antidepressant class is associated with the adverse effects including lowering seizure threshold, QT prolongation, bleeding risk, sexual dysfunction?

Answer 129

SSRIs Quickly boost Spirits S - Seizure threshold lowered Q - QT interval prolongation B - Bleeding risk increased S - Sexual dysfunction

Question 130

The following questions relate to SSRI interactions: 1) Increases plasma conc of Metoprolol, Aripiprazole, TCAs & Ranolazine 2) Carbamazepine reduces conc of this SSRI 3) These two reduce the plasma conc of Tamoxifen ``` A) Sertraline B) Citalopram C) Fluoxetine D) Paroxetine E) Escitalopram ```

Answer 130

1) Paroxetine 2) Sertraline 3) Fluoxetine & Paroxetine

Question 131

List 3 positive and 3 negative symptoms of Schizophrenia

Answer 131

Positive symptoms: 1. Thought disorder 2. Hallucinations 3. Delusions Negative symptoms: 1. Social withdrawal 2. Apathy [lack of interest/enthusiasm] 3. Withdrawn

Question 132

Which two of the below statements are correct: A) Antipsychotics are more effective in relieving positive psychotic symptoms and less effective on negative symptoms B) Antipsychotics are more effective in relieving negative psychotic symptoms and less effective on positive symptoms C) 1st generation are better at treating negative symptoms D) 2nd generation are better at treating negative symptoms

Answer 132

A) Antipsychotics are more effective in relieving positive psychotic symptoms and less effective on negative symptoms D) 2nd generation are better at treating negative symptoms

Question 133

Which of the following is not an example of a 1st generation antipsychotic? ``` A) Chlorpromazine B) Prochlorperazine C) Promazine D) Aripiprazole E) Zuclopenthixol ```

Answer 133

D) Aripiprazole is 2nd generation Azines are 'ol' school

Question 134

True or false: Clozapine, Amisulpride, Olanzapin, Risperidone & Quetiapine are all examples of 2nd generation antipsychotics

Answer 134

True 2nd generation end in "apine" or "one"

Question 135

True or false "2nd generation antipsychotics are associated with more extrapyramidal symptoms (EPS) compared to 1st generation"

Answer 135

False - 1st generation = more EPS

Question 135

Match the statements to the answers (1st gen or 2nd gen antipsychotics) 1) These act mainly by blocking D2 receptors in the brain 2) These act on a variety of receptors but are more selective, act on specific D receptors 3) These are better at treating negative symptoms 4) These are non-selective for any of the 4 dopamine pathways in brain (hence can cause range of S.E esp EPS & elevated prolactin)

Answer 135

1) 1st gen 2) 2nd gen 3) 2nd gen 4) 1st gen

Question 136

1st generation antipsychotics can be split into 3 groups Rank the groups from most to least that cause EPS

Answer 136

Most EPS - Group 3 Middle EPS - Group 1 Least EPS - Group 2

Question 137

Which 3 antipsychotics are the most sedating?

Answer 137

Phenothiazines ("mazine") including Chlorpromazine, Levomepromazine & Promazine (OTC) are the most sedative

Question 138

Match these 2nd generation antipsychotics with the following statements: Clozapine | Aripiprazole | Amisulpride & Ripseridone | Olanzapine 1. Most hyperprolactinaemia 2. No hyperprolactinaemia 3. Most weight gain and diabetes 4. Agranulocytosis, myocarditis, G.I. obstruction, weight gain & diabetes

Answer 138

1. Amisulpride & Risperidone cause most hyperprolactinaemia 2. Aripiprazole doesn't cause hyperprolactinaemia 3. Olanzapine causes most weight gain and diabetes 4. Clozapine causes agranulocytosis, myocarditis, G.I. obstruction, weight gain & diabetes

Question 139

Which of the following statements in incorrect A) Antipsychotics can be given to elderly patients to treat mild to moderate psychotic symptoms B) Antipsychotics are related to stroke, TIA and mortality in elderly patients with dementia C) Elderly patients are more suscebtile to postural hypotension & hypothermia in hot or cold weather D) Initial doses of antipsychotics should be reduced in elderly & treatment should be reviewed regularly E) Antipsychotics should only be given in the elderly if the benefits outweigh the risks

Answer 139

A) Antipsychotics can be given to elderly patients to treat mild to moderate psychotic symptoms This is incorrect because antipsychotics in elderly should only be used to treat severe psychotic symptoms

Question 140

List 5 extrapyramidal symptoms associated with antipsychotics

Answer 140

Memory Trick: ADAPPT ``` AD - Acute Dystonia A - Akathisia P - Parkinsonism P - Prolactinaemia T - Tardive dyskinesia ```

Question 141

Match the EPS to its description Acute Dystonia | Akathisia | Parkinsonism | Tardive dyskinesia 1) Tremor, rigidity, bradykinesia 2) Rhythmic, involuntary movements of jaw, tongue & face 3) Involuntary contractions of muscle anywhere in body 4) Restlessness, can't stay still

Answer 141

1) Parkinsonism 2) Tardive dyskinesia 3) Acute Dystonia 4) Akathisia

Question 142

Match the EPS with their onset of duration Akathisia | Acute Dystonia Tardive dyskinesia | Parkinsonism 1) Rapid (hours-days): treated by 1st generation antihistamines (Diphenhydramine) 2) Days - weeks: treated by BBB (Beta Blockers, Benzodiazepines) 3) Weeks - months: treated by Amantadine 4) >6 months: treated by Clozapine

Answer 142

1) Acute Dystonia 2) Akathisia 3) Parkinsonism 4) Tardive dyskinesia

Question 143

Which EPS is irreversible? A) Akathisia B) Tardive Dyskinesia C) Parkinsonism D) Acute Dystonia

Answer 143

B) Tardive dyskinesia

Question 144

List 5 symptoms of hyperprolactinaemia

Answer 144

1. Sexual dysfunction 2. Reduced bone density 3. Breast enlargement 4. Menstrual changes 5. Galactorrhoea

Question 145

Match the medication which should be avoided in these S/E 1. Weight gain (2) 2. Diabetes/hyperglycaemia (4) 3. Postural hypotension (2) 4. Hyperprolactinaemia (4) 5. Cardiac S/E (1) 6. Decreased libido (2) 7. EPS (1) 8. Sexual dysfunction (3) ``` A) Olanzapine B) Quetiapine C) Haloperidol D) Fluphenazine E) Risperidone F) Amisulpride G) Prochlorperazine H) Aripiprazole I) Flupenthixol J) ALL esp Pimozide K) 1st gen antipsychotics L) Clozapine M) Sulphide ```

Answer 145

1) Weight gain - Clozapine & Olanzapine 2) Diabetes/hyperglycaemia - Risperidone, Quetiapine, Clozapine & Olanzapine 3) Postural hypotension - Clozapine & Quetiapine 4) Hyperprolactinaemia - Risperidone, Amisulpride, Sulphide & 1st gen 5) Cardiac S/E - All antipsychotics esp Pimozide 6) Decreased libido - Risperidone & Haloperidol 7) EPS - 1st gen 8) Sexual dysfunction - Risperidone, Haloperidol & Olanzapine

Question 146

Match the medication which is suitable in these S/E 1. Weight gain (3) 2. Diabetes/hyperglycaemia (3) 3. Postural hypotension 4. Hyperprolactinaemia (3) 5. Cardiac S/E (6) 6. Decreased libido 7. EPS (4) 8. Sexual dysfunction (2) ``` A) Olanzapine B) Quetiapine C) Haloperidol D) Fluphenazine E) Risperidone F) Amisulpride G) Prochlorperazine H) Aripiprazole I) Flupenthixol J) 1st gen K) 2nd gen ```

Answer 146

1) Weight gain - Amisulpride, Aripiprazole, Haloperidol 2) Diabetes/hyperglycaemia - 1st gen, Haloperidol, Fluphenazine 3) Postural hypotension - 0 4) Hyperprolactinaemia - Aripiprazole, Clozapine, Quetiapine 5) Cardiac S/E - Aripiprazole, Clozapine, Olanzapine, Risperidone, Prochloperazine, Flupenthixol 6) Decreased libido - 0 7) EPS - 2nd gen 8) Sexual dysfunction - Aripiprazole & Quetiapine

Question 147

What are the monitoring requirements of antipsychotics?

Answer 147

- FBC, U&Es, LFTs at start and then annually - Lipids, weight, fasting glucose, ECG - BP, prolactin conc, physical health monitoring (inc CVD risk) annually

Question 148

Which of the following regarding the treatment cessation of antipsychotics is incorrect? A) There is a high risk of relapse if antipsychotics are stopped after 1-2 years B) Withdrawal after long term should be gradual C) Patients should be monitored for 3 years after withdrawal for signs of relapse

Answer 148

C is incorrect because patients should be monitored for 2 years after withdrawal for signs of relapse

Question 149

Mr H suffers from psychosis in Parkinson's disease but has been unresponsive to conventional antipsychotics. Which drug would you expect to be prescribed for this?

Answer 149

Clozapine

Question 150

List 3 MHRA warnings for Clozapine Hint (MAG)

Answer 150

1. Myocarditis & cardiomyopathy - tachycardia 2. Agranulocytosis & neutropenia (report flu) 3. Gastrointestinal Obstruction - Constipation

Question 151

List the Clozapine mnemonic [CLOSE DA BLOODY DOOR]

Answer 151

Close Door - Last option DA - Dopamine & Alpha 1 receptor inhibitor Bloody - Agranulocytosis/blood disorders

Question 152

What would you offer to patients who cannot comply with oral antipsychotics? Give 2 examples of these

Answer 152

Long-acting depot injections (however, they have more EPSE) 1. Zupenthixol (prevents relapse) 2. Flupenthixol (agitated & aggressive patients)

Question 153

Match the symptoms of motor neurone disease to their treatment 1) Muscle stiffness 2) Saliva problems 3) Thick tenacious saliva 4) Respiratory 5) Amyotrophic lateral sclerosis (motor neuron disease) A) Riluzole B) Antimuscarinics, glycopyrronium or botulinum toxin A C) Opioids or benzodiazepines D) Baclofen, Tizanidine, Dantrolene & Gabapentin E) Humidification [moisture], nebulisers & Carbocisteine

Answer 153

1) D: Muscle stiffness = Baclofen, Tizanidine, Dantrolene & Gabapentin 2) B - Saliva problems = Antimuscarinics, glycopyrronium or botulinum toxin A 3) E - Humidification [moisture], nebulisers & Carbocisteine 4) C - Respiratory = Opioids [breathlessness] or benzodiazepines [anxiety] 5) A - Motor neuron disease = Riluzole

Question 154

The following questions relate to treatment of motor neurone disease: 1) 1st line treatment for muscle cramps 2) 2nd line treatment for muscle cramps 3) List 3 other options to treat muscle cramps

Answer 154

1) 1st Line - Quinine 2) 2nd Line - Baclofen 3) Tizanidine, Dantrolene sodium & Gabapentin

Question 155

List 5 motor symptoms of Parkinsons Disease

Answer 155

1) Hypokinesia [small movements] 2) Bradykinesia [slow movements] 3) Rigidity 4) Rest tremor 5) Postural instability Motor = Movement

Question 156

List 7 non-motor symptoms of Parkinsons Disease

Answer 156

1) Dementia 2) Depression 3) Sleep disturbances 4) Bladder & bowel dysfunction 5) Speech & language changes 6) Swallowing problems 7) Weight loss

Question 157

List 4 non-drug treatments for Parkisons Disease

Answer 157

1) Physiotherapy 2) Speech & language therapy 3) Occupational therapy 4) Dietician

Question 158

List 3 antimuscarinics used in parkinsons

Answer 158

1) Trihexyphenidyl 2) Orphenadrine 3) Procyclidine

Question 159

Match these dopaminergic drug classes to their examples 1) D precursors-Levodopa 2) D receptor agonists 3) Catechol-o-methyltransferase inhibitors 4) Monoamine-oxidase B inhibitors A) Rasagaline, Selegiline & Safinamide B) Amantadine, Apomorphine, Bromocriptine, Cabergoline, Pergolide, Pramipexole, Ropinirole, Rotigotine C) Entacapone, Opicapone, Tolcapone D) Co-Beneldopa, Co-Careldopa

Answer 159

1) D: Dopamine precursors-Levodopa = Co-Beneldopa, Co-Careldopa 2) B: D receptor agonists = Amantadine, Apomorphine, Bromocriptine, Cabergoline, Pergolide, Pramipexole, Ropinirole, Rotigotine 3) C: Catechol-o-methyltransferase inhibitors = Entacapone, Opicapone, Tolcapone 4) A: Monoamine-oxidase B inhibitors = Rasagaline, Selegiline & Safinamide

Question 160

Name 2 drugs which can be used as first line-treatment for the management of the motor symptoms of Parkinsons which decrease life?

Answer 160

1. Co-Careldopa (Levodopa + Carbidopa) | 2. Co-Beneldopa (Levodopa + Benserazide)

Question 161

Name 3 drugs or drug classes that are used in the management of the motor symptoms of Parkinsons which do not affect quality of life?

Answer 161

1. Levodopa 2. Non-ergot derived dopamine receptor agonists (Pramipexole, Ropinirole or Rotigotine) 3. MAO-B Inhibitors (Rasagiline ot Selegiline)

Question 162

Mr P is currently taking Levodopa and requires adjunctive therapy. He has tried Pramipexole but cannot tolerate it. Name a drug you would deem appropriate to prescribe?

Answer 162

Non-ergot derived dopamine agonists such as: 1. Bromocriptine 2. Cabergoline 3. Pergolide

Question 163

Which antiparkinson drug would you expect to be given to a patient who is experiencing dyskinesia where their existing modifying therapy is not adequately managed?

Answer 163

Amantadine

Question 164

A patient suffers from excessive daytime sleepiness and sudden onset of sleep? Which of the following is most suitable for this patient? ``` A) Levodopa B) Bromocriptine C) Pramipexole D) Modafinil E) Rotigitine ```

Answer 164

4) Modafinil Treatment with this should be reviewed annually and patients should be advised not to drive (inform DVLA)

Question 165

A patient suffers from nocturnal akinesia (inability to turn in bed or risk to pass urine at night). Which drugs are first and second line for this?

Answer 165

1st line = Levodopa or oral dopamine receptor agonist 2nd line = Rotigotine

Question 166

Which 2 drugs are used first and as an alternative for postural (orthostatic) hypotension in Parkinson's disease?

Answer 166

1st line = Midodrine hydrochloride Alternative = Fludrocortiosne

Question 167

Name 2 drugs that can be given to manage rapid eye movement sleep behaviour disorder in Parkinsons disease?

Answer 167

1. Clonazepam | 2. Melatonin

Question 168

Name the first and second line for the management of drooling saliva in Parkinson's disease

Answer 168

1st line = Glycopyrronium bromide 2nd line = Botulinum toxin type A

Question 169

1. Which drug (administered via injection or infusion) would be given to manage advanced Parkinsons disease? 2. Which anti-emetic would be given to counter the N&V S/E from this drug? 3. Which anti-emetic should be avoided in managing N&V S/E in Parkinsons disease due to an increased risk of EPSE?

Answer 169

1. Apomorphine hydrochloride 2. Domperidone 3. Metoclopramide

Question 170

1. Give 2 examples of COMT Inhibitors used as adjunctive therapy for Levopdopa 2. Which of these COMT inhibitors colours urine reddish brown and which one is associated with liver toxicity?

Answer 170

1. Tolcapone and Entacapone 2 (i) Tolcapone = Liver toxicity 2 (ii) Entacapone = colours urine reddish brown

Question 171

Which 2 of the following can be given to treat N&V in terminal illness (palliative care)? ``` A) Prochlorperazine B) Haloperidol C) Levopromazine D) Ondansetron E) Aprepitant F) Cyclizine ```

Answer 171

B) Haloperidol | C) Levopromazine

Question 172

Which of the following is used for GI-associated N&V? ``` A) Prochlorperazine B) Haloperidol C) Levopromazine D) Ondansetron E) Metoclopramide ```

Answer 172

E) Metoclopramide

Question 173

Which of the following can be used for Parkinson's-induced N&V? ``` A) Prochlorperazine B) Domperidone C) Levopromazine D) Ondansetron E) Metoclopramide ```

Answer 173

B) Domperidone Acts at the chemoreceptor trigger zone (doesn't cross BBB, so less sedating and less dystonic S.E compared to Metoclopramide)

Question 174

Which of the following cannot used for post-operative N&V and chemotherapy-induced N&V? ``` A) Promethazine B) Apripetant C) Dexamethasone D) Ondansetron E) Palonosetron ```

Answer 174

A) Promethazine

Question 175

Which of the following is used for chemotherapy-induced anticipatory vomiting? ``` A) Dexamethasone B) Cyclizine C) Clonazepam D) Lorazepam E) Ondansetron ```

Answer 175

D) Lorazepam

Question 176

Which of the following is given in chemotherapy-induced N&V to patients who have been unresponsive to other anti-emetics? ``` A) Ondansetrin B) Apripetant C) Dexamethasone D) Nabilone E) Promethazine ```

Answer 176

D) Nabilone Synthetic cannabinoid as an add-on for chemo-induced N&V as last option

Question 177

Which of the following is given as a buccal tablet in migraines but can also be used in severe N&V? ``` A) Promethazine B) Prochlorperazine C) Chlorpromazine D) Levopromazine E) Perphenazine ```

Answer 177

B) Prochlorperazine

Question 178

Which of the following is used to treat vertigo, tinnitus, and hearing loss associated with Meniere’s disease? ``` A) Prochlorperazine B) Betahistine C) Domperidone D) Promethazine E) Hyoscine hydrobromide ```

Answer 178

B) Betahistine

Question 179

Which of the following is used to treat motion sickness? ``` A) Prochlorperazine B) Betahistine C) Domperidone D) Metclopramide E) Hyoscine hydrobromide ```

Answer 179

E) Hyoscine hydrobromide

Question 180

A patient has taken an anti-emetic and reports symptoms of arrythmia (palpitations or syncope). Which of the following anti-emetic do you expect this patient is taking? ``` A) Metoclopramide B) Promethazine C) Domperidone D) Prochlorperazine E) Cyclizine ```

Answer 180

C) Domperidone

Question 181

Mr P is taking an anti-emetic and reports neurological adverse effects. Which of the following anti-emetic do you expect this patient is taking? ``` A) Metoclopramide B) Promethazine C) Domperidone D) Prochlorperazine E) Cyclizine ```

Answer 181

A) Metoclopramide

Question 182

Miss C comes to your pharmacy and asks for your advice regarding her 5-year old son who is currently experiencing a cough. Which of the following is least appropriate for this patient? ``` A) Simple linctus paediatric B) Calcough Children's syrup C) Phenergan elixir D) Bronchostop junior E) Neurofen children ```

Answer 182

C) Phenergan elixir The active ingredient in Phenergan is Promethazine. Children under 6 years should not be given OTC cough & cold medicines containing Promethazine