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Asim's Clinical Pre Reg Questions > Central Nervous System > Flashcards

Central Nervous System Flashcards

1
Q

Name the 5 types of dementia

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

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

A

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
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3
Q

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
A

Memantine hydrochloride [NMDA Glutamine Receptor Antagonist]

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4
Q

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?
A
  1. Donepezil & Rivastigmine
  2. Galantamine
  3. Memantine
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5
Q

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?

A
  1. Acetylcholinesterase inhibitors

2. Memantine hydrochloride

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6
Q

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?
A
  1. AChEIs & Memantine are NOT recommended to treat frontotemporal dementia
  2. NO CURE — antidepressants or antipsychotics can be used to relieve symptoms
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7
Q

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

A

Drugs that cause antimuscarinic effects include:

  1. Antidepressants — Amitriptyline & Paroxetine
  2. Antihistamines — Chlorphenamine & Promethazine
  3. Antipsychotics — Olanzapine & Quetiapine
  4. Urinary spasmodics — Solifenacin & Tolteradine
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8
Q

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

A

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

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9
Q

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?
A
  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]
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10
Q

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?
A
  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.
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11
Q

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
A
  1. Benzodiazepines (Oral) or Antipsychotics

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

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12
Q

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?
A
  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
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13
Q

What are the 2 MHRA Warnings for anti-epileptics

A
  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]
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14
Q

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

A

CPR3

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

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15
Q

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
A
  1. Category 2

2. Category 3

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16
Q

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

A

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

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17
Q

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?
A
  1. Fever, rash, & lymphadenopathy (swollen or enlarged lymph nodes)
  2. 1-8 weeks after starting [monitor in first 2 weeks]
  3. Withdrawal immediately
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18
Q

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
A
  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
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19
Q

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

A

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.

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20
Q

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

A

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]
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21
Q

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?

A
  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
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22
Q

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

A

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)
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23
Q

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.

A
  1. Teratogenicity
  2. First
  3. Two or more
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24
Q

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

A

CPR3 & Lamotrigine

  1. Carbamazepine
  2. Phenobarbital
  3. Phenytoin
  4. Primidone
  5. Lamotrigine
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25
Q

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

A

Topiramate = cleft palate

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26
Q

Name 2 anti-epileptics that require monitoring of foetal growth

A
  1. Topiramate

2. Levetiracetam

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27
Q

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

A

Vitamine K injection

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28
Q

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

A

Folic Acid 5mg daily:

  1. Before conception
  2. During 1st trimester
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29
Q

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?
A
  1. ZELP - (Zonisamide, Ethosuximide, Lamotrigine, Primidone)

2. Phenobarbital and Lamotrigine

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30
Q

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

A
  1. Phenobarbital

2. Primidone

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31
Q

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

A
  1. Phenobarbital
  2. Primidone
  3. Benzodiazepines
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32
Q

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

A
  1. Carbamazepine
  2. Lamotrigine

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

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33
Q

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

A
  1. Oxcarbazepine
  2. Sodium Valproate
  3. Levetiracetam
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34
Q

Name the 4 different types of generalised seizures

A
  1. Tonic-clonic seizures
  2. Absence seizures
  3. Myoclonic seizures
  4. Atonic & Tonic seizures
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35
Q

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
A

Tonic-clonic seizure

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

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36
Q

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
A

Absence Seizure

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37
Q

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

A

Myoclonic seizure

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38
Q

Which type of generalised seizure is described as the following:

  1. Brief loss of consciousness
  2. Stiffness
  3. Fall to the ground
A

Atonic & Tonic Seizure

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39
Q

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

A

Sodium Valproate

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40
Q

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)
A
  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
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41
Q

Answer the following questions regarding absence seizures:

  1. First-line treatment (2 drugs)
  2. Alternative treatment (1 drug)
A
  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

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42
Q

Answer the following questions regarding myoclonic seizures:

  1. First-line treatment (1 drug)
  2. Alternative treatment (2 drugs)
A
  1. First-line for myoclonic seizures = Sodium Valproate
  2. Alternative for myoclonic seizures = Levetiracetam & Topiramate

Memory Trick:
SALT = Sodium Valproate. Alternatively, Levetiracetam, Topiramate

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43
Q

Answer the following questions regarding atonic & tonic seizures:

  1. First-line treatment (1 drug)
  2. Adjunctive treatment (1 drug)
  3. Alternative treatment (2 drugs)
A
  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

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44
Q

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

A
  1. Absence
  2. Mycolonic
  3. Atonic & Tonic
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45
Q

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

A

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

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46
Q

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
A

D) Carbamazepine

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

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47
Q

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?

A

Lamotrigine

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48
Q

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
A

F) Lacosamide

Explanation:
Think “C Vet Plz”

C - Carbamazepine
V - Valproate
E - Ethosuximide
T - Topiramate
P - Phenytoin
L - Lamotrigine
Z - Zonisamide
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49
Q

Which anti-epileptic is associated with visual field defects?

A) Lamotrigine
B) Valproate
C) Carbamazepine
D) Vigabatrin
E) Topiramate
A

D) Vigabatrin

Think Vi for Vigabatrin and Vi for Visual

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50
Q

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
A

E) Topiramate

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51
Q

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
A

D) Vigabatrin

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52
Q

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?

A

1) Focal seizures with or without secondary generalisation

2) Generalised anxiety disorder

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53
Q

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

A

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)

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54
Q

Which anti-epileptic is an enzyme inhibitor which therefore, increases plasma concentration (Cp)?

A) Phenytoin
B) Carbamazepine
C) Valproate
D) Phenobarbital

A

C) Valproate

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

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55
Q

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

A

Phenytoin is indicated for focal seizures and tonic-clonic seizures

Phenytoin must be avoided in absence and myoclonic seizures

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56
Q

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)

A

B) 10-20 mg/L (40-80 micromol/L)

Neonate <3m have a therapeutic range of 6-15mg/L or 25-50micromol/L

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57
Q

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
A

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

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58
Q

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

A

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

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59
Q

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
A

C) Intramuscular injection

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60
Q

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
A

E) Phenytoin

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61
Q

How long does convulsive status epilepticus last?

A) >2 mins
B) >3 mins
C) >4 mins
D) >5 mins
E) >6 mins
A

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

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62
Q

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?

A

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

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63
Q

Which of the following is not an example of a long-acting benzodiazepine?

A) Alprazolam
B) Clobazam
C) Chlordiazepoxide
D) Diazepam
E) Midazolam
A

E) Midazolam (SA benzodiazepine)

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64
Q

Which of the following is not an example of a short-acting benzodiazepine?

A) Midazolam
B) Tempazem
C) Loprazolam
D) Alprazolam
E) Lometazepam
A

D) Alprazolam (LA benzodiazepine)

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65
Q

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

A

Temazepam or Diazepam

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66
Q

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

A

Melatonin (pineal hormone)

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67
Q

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?

A

Buspirone

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68
Q

Which very short-acting barbiturate is used in anaesthesia?

A

Thiopental

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69
Q

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)?

A

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

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70
Q

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
A

B) 2-4 weeks

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71
Q

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?

A

C) 1-2mg every 2-4 weeks.

Can reduce Diazepam further if needed in smaller steps of 500mcg towards the end. Then completely stop

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72
Q

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

A
  1. Diazepam

2. Lorazepam

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73
Q

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

A
  1. Avoid prolonged use
  2. Avoid abrupt withdrawal
  3. Avoid in pts with a history of drug/alcohol dependence
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74
Q

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
A

C) Renal impairment

75
Q

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
A

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
76
Q

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

A
  1. Lisdexamfetamine

2. Methylphenidate

77
Q

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

A
  1. Atomoxetine

2. Dexamfetamine

78
Q

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
A

D) Atomoxetine

79
Q

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

A
  1. Affects driving

2. Effects increased by alcohol

80
Q

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
A

D) Atomoxetine

81
Q

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

A
  1. Lithium
  2. Valproate
  3. Carbamazepine
  4. Antipsychotics
  5. Benzodiazepines
82
Q

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?
A
  1. Two years at least

2. Up to five years

83
Q

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

A

Antidepressants

84
Q

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?
A
  1. Olanzapine, Quetiapine & Risperidone

2. Lithium or Valproate

85
Q

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
A

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

86
Q

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
A

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

87
Q

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?

A

Carbamazepine

88
Q

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

A

Valproate

89
Q

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?

A

Lithium salts

90
Q

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
A

D) 6-12 months

91
Q

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
A

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

92
Q

Which of the following is not an interaction associated with Lithium?

A) QT interval prolongation
B) Hypokalaemia
C) CCBs
D) ACE-I
E) NSAIDs
A

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

93
Q

Name each letter of the ‘LITHIUMS’ S/E mnemonic

A

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]

94
Q

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?

A
  1. Cardiac function
  2. Thyroid function
  3. Renal function
  4. U&Es
  5. FBC
  6. BMI
95
Q

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

A

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

96
Q

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

A

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

97
Q

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

A

L - Lithium interacts with:
A - ACE-I/ARBs
N - NSAIDs
D - Diuretics

M - Metronidazole
A - Amiodarone
T - Tetracyclines

98
Q

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

A

B) Ramipril

99
Q

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
A

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]
100
Q

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
A

E) Amitriptyline

Drugs which increase the risk of serotonin syndrome with Lithium include:

  • SSRIs
  • MOAIs (Rasagiline)
  • St John’s Wort
  • Triptans
  • Tramadol
101
Q

Name the 3 major classes of antidepressants and one other class

A
  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]
102
Q

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

A

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

103
Q

Give 2 examples of tetracyclic antidepressants

A
  1. Trazodone

2. Manserin

104
Q

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

A

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

105
Q

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

A

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

106
Q

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?
  3. What is the first noticable benefit of drug therapy?
  4. What does paradoxical effects of antidepressants mean?
A

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)

107
Q

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

A

SSRIs

  1. Better tolerated & safer in overdose
  2. Less sedating
  3. Fewer antimuscarinic & cardiotoxic effects
108
Q

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

A

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

109
Q

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
A

D) Hyponatraemia

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

110
Q

Name the words of the ‘SALT LOSS’ mneomnic for the signs of hyponatraemia

A

S - Stupor/coma
A - Anorexia
L - Lethargy
T - Tendon reflexes (decreased)

L - Limp muscles (weakness)
O - Orthostatic hypotension
S - Seziures/headaches
S - Stomach cramps

111
Q

Name 6 symptoms of serotonin syndrome

Hint: Serotonin syndrome makes chemists doubly annoyed

A
  1. Sweating
  2. Shivering
  3. Muscle twitching
  4. Confusion
  5. Diarrhoea
  6. Agitation
112
Q

Name 6 drugs which cause serotonin syndrome when taken concomitantly

(Hint: Many Lovely Therapists Like Serotonin Syndrome)

A
  1. MAOIs
  2. Lithium
  3. Triptans
  4. Lisdexamfetamine
  5. St John’s Wort
  6. SSRIs
113
Q

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?

A
  1. Increase dose to 100mg OD
  2. Switch to a different SSRI (e.g., Citalopram 10mg OD)
  3. Initiate Mirtazapine 15mg ON
114
Q

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

A

Venlafaxine

115
Q

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

A
  1. Lofepramine (TCA)
  2. Reboxetine
  3. Moclobemide (reversible MAOI)
116
Q

Name 3 third line options for depression

A
  1. Add another antidepressant class
  2. Add Lithium
  3. Add an antipsychotic
117
Q

Which of the following is not considered as a less sedating TCA?

A) Nortriptyline
B) Imipramine
C) Amitriptyline
D) Lofepramine

A

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

118
Q

List 6 TCAs with sedating properties that are used for agitated & anxious patients

(HINT: Amitriptyline Can Triple The Daytime Drowsiness)

A
  1. Amitriptyline
  2. Clomipramine
  3. Trazodone
  4. Trimipramine
  5. Dosulepin
  6. Dozepin
119
Q

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

A

T - More toxic in overdose than SSRIs

C - Cardiac S/E [QT prolongation, heart block, hypertension, arrhythmia etc]

A - Antimuscarinic S/E

S - Seizures

120
Q

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

A 
A - Anorexia
B - Blurry vision
C - Constipation/confusion
D - Dry mouth
S - Static urine
121
Q

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

A
  • Can’t Pee
  • Can’t See
  • Can’t Spit
  • Can’t Shit
122
Q

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

A

Lithium

123
Q

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
A

B) MAOIs

124
Q

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
A

C) Phenylephrine

125
Q

Explain the memory trick for MAOI = MAOOI

A

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

126
Q

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

A

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

127
Q

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
A
  1. 3 weeks
  2. 1 week
  3. 1-2 weeks
  4. 5 weeks
  5. 2 weeks [0 for Moclobemide]
  6. 2 weeks
128
Q

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]

A

(i) Tyramine

(ii) Two

129
Q

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

A

SSRIs Quickly boost Spirits

S - Seizure threshold lowered
Q - QT interval prolongation
B - Bleeding risk increased
S - Sexual dysfunction

130
Q

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
A

1) Paroxetine
2) Sertraline
3) Fluoxetine & Paroxetine

131
Q

List 3 positive and 3 negative symptoms of Schizophrenia

A

Positive symptoms:

  1. Thought disorder
  2. Hallucinations
  3. Delusions

Negative symptoms:

  1. Social withdrawal
  2. Apathy [lack of interest/enthusiasm]
  3. Withdrawn
132
Q

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

A

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

133
Q

Which of the following is not an example of a 1st generation antipsychotic?

A) Chlorpromazine
B) Prochlorperazine
C) Promazine
D) Aripiprazole
E) Zuclopenthixol
A

D) Aripiprazole is 2nd generation

Azines are ‘ol’ school

134
Q

True or false:

Clozapine, Amisulpride, Olanzapin, Risperidone & Quetiapine are all examples of 2nd generation antipsychotics

A

True

2nd generation end in “apine” or “one”

135
Q

True or false

“2nd generation antipsychotics are associated with more extrapyramidal symptoms (EPS) compared to 1st generation”

A

False - 1st generation = more EPS

135
Q

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)

A

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

136
Q

1st generation antipsychotics can be split into 3 groups

Rank the groups from most to least that cause EPS

A

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

137
Q

Which 3 antipsychotics are the most sedating?

A

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

138
Q

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
A
  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
139
Q

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

A

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

140
Q

List 5 extrapyramidal symptoms associated with antipsychotics

A

Memory Trick: ADAPPT

AD - Acute Dystonia
A - Akathisia
P - Parkinsonism
P - Prolactinaemia
T - Tardive dyskinesia
141
Q

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

A

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

142
Q

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

A

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

143
Q

Which EPS is irreversible?

A) Akathisia
B) Tardive Dyskinesia
C) Parkinsonism
D) Acute Dystonia

A

B) Tardive dyskinesia

144
Q

List 5 symptoms of hyperprolactinaemia

A
  1. Sexual dysfunction
  2. Reduced bone density
  3. Breast enlargement
  4. Menstrual changes
  5. Galactorrhoea
145
Q

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
A

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

146
Q

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
A

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

147
Q

What are the monitoring requirements of antipsychotics?

A
  • FBC, U&Es, LFTs at start and then annually
  • Lipids, weight, fasting glucose, ECG
  • BP, prolactin conc, physical health monitoring (inc CVD risk) annually
148
Q

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

A

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

149
Q

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?

A

Clozapine

150
Q

List 3 MHRA warnings for Clozapine

Hint (MAG)

A
  1. Myocarditis & cardiomyopathy - tachycardia
  2. Agranulocytosis & neutropenia (report flu)
  3. Gastrointestinal Obstruction - Constipation
151
Q

List the Clozapine mnemonic [CLOSE DA BLOODY DOOR]

A

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

152
Q

What would you offer to patients who cannot comply with oral antipsychotics?

Give 2 examples of these

A

Long-acting depot injections (however, they have more EPSE)

  1. Zupenthixol (prevents relapse)
  2. Flupenthixol (agitated & aggressive patients)
153
Q

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

A

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

154
Q

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

A

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

155
Q

List 5 motor symptoms of Parkinsons Disease

A

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

Motor = Movement

156
Q

List 7 non-motor symptoms of Parkinsons Disease

A

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

157
Q

List 4 non-drug treatments for Parkisons Disease

A

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

158
Q

List 3 antimuscarinics used in parkinsons

A

1) Trihexyphenidyl
2) Orphenadrine
3) Procyclidine

159
Q

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

A

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

160
Q

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

A
  1. Co-Careldopa (Levodopa + Carbidopa)

2. Co-Beneldopa (Levodopa + Benserazide)

161
Q

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?

A
  1. Levodopa
  2. Non-ergot derived dopamine receptor agonists (Pramipexole, Ropinirole or Rotigotine)
  3. MAO-B Inhibitors (Rasagiline ot Selegiline)
162
Q

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?

A

Non-ergot derived dopamine agonists such as:

  1. Bromocriptine
  2. Cabergoline
  3. Pergolide
163
Q

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?

A

Amantadine

164
Q

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
A

4) Modafinil

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

165
Q

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?

A

1st line = Levodopa or oral dopamine receptor agonist

2nd line = Rotigotine

166
Q

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

A

1st line = Midodrine hydrochloride

Alternative = Fludrocortiosne

167
Q

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

A
  1. Clonazepam

2. Melatonin

168
Q

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

A

1st line = Glycopyrronium bromide

2nd line = Botulinum toxin type A

169
Q
  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?
A
  1. Apomorphine hydrochloride
  2. Domperidone
  3. Metoclopramide
170
Q
  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?
A
  1. Tolcapone and Entacapone

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

171
Q

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
A

B) Haloperidol

C) Levopromazine

172
Q

Which of the following is used for GI-associated N&V?

A) Prochlorperazine
B) Haloperidol
C) Levopromazine
D) Ondansetron
E) Metoclopramide
A

E) Metoclopramide

173
Q

Which of the following can be used for Parkinson’s-induced N&V?

A) Prochlorperazine
B) Domperidone
C) Levopromazine
D) Ondansetron
E) Metoclopramide
A

B) Domperidone

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

174
Q

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
A

A) Promethazine

175
Q

Which of the following is used for chemotherapy-induced anticipatory vomiting?

A) Dexamethasone
B) Cyclizine
C) Clonazepam
D) Lorazepam
E) Ondansetron
A

D) Lorazepam

176
Q

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
A

D) Nabilone

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

177
Q

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
A

B) Prochlorperazine

178
Q

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
A

B) Betahistine

179
Q

Which of the following is used to treat motion sickness?

A) Prochlorperazine
B) Betahistine
C) Domperidone
D) Metclopramide
E) Hyoscine hydrobromide
A

E) Hyoscine hydrobromide

180
Q

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
A

C) Domperidone

181
Q

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
A

A) Metoclopramide

182
Q

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
A

C) Phenergan elixir

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

Asim's Clinical Pre Reg Questions (11 decks)

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