Central Nervous System Flashcards
1
Q
What are the symptoms of dementia?
A
Memory loss
Difficult thinking
Psychiatric/behavioural problems
Language issues
2
Q
What are the 3 acetylcholinesterase inhibitors used for mild-moderate alzheimers disease?
A
- Donepezil
- Galantamine
- Rivastigmine
3
Q
Which acetylcholinesterase should be stopped at the firsts sign of a skin rash (SJS)?
A
Galantamine
4
Q
Which drug is used in moderate-severe alzheimers disease?
A
Memantine
5
Q
What are some examples of cholinergic side effects?
A
Remember DUMB BELLS
Diarrhoea
Urination
Muscle weakness
Broncho-spasms
Bradycardia
Emesis
Lacrimation
Salivation/sweating
6
Q
What is there an increased risk of when patients with dementia are given antipsychotics?
A
Increased risk of stroke and death
Must be started on a low dose and titrated upwards
7
Q
Which antipsychotics are recommended in dementia patients?
A
IM haloperidol, or risperidone
Olanzapine
8
Q
Which anti-epileptics have a long half life, and are hence given ONCE a day?
A
Phenytoin
Lamotrigine
Perampanel
Phenobarbital
9
Q
What are the 1st and 2nd line drug treatments for focal (partial seizures)?
A
1st: lamotrigine or levetiracetam
2nd: carbamazepine
10
Q
What are the 1st and 2nd line treatment options for tonic-clonic seizures?
A
1st: valproate
2nd: lamotrigine, levetiracetam
11
Q
What are the 1st and 2nd line treatment options for absence seizures?
A
1st: ethosuximide or valproate
2nd: lamotrigine
12
Q
What are the category 1 anti-epileptic drugs, and what does this mean?
A
Remember CP3
Carbamazepine, phenytoin, phenobarbital, primidone
These must be prescribed by brand and are not interchangeable
13
Q
What are the category 2 anti-epileptic drugs, and what does this mean?
A
Remember TVLC
Topiramate
Valproate
Lamotrigine
Clonazepam
These can be switched between them, based on patient needs and clinical judgement
14
Q
What are the category 3 anti-epileptic drugs, and what does this mean?
A
Remember GLP
Gabapentin
Levetiracetam
Pregabalin
These are not necessary to be prescribed by brand
15
Q
What can sudden withdrawal of anti-epileptic drugs cause?
A
Severe rebound seizures
16
Q
How long should epileptic patients not drive for if they have had an unprovoked or single isolated seizure?
A
6 months
17
Q
How long should patients wait till they can drive again once they have been initially diagnosed?
A
1 year
18
Q
Which category of anti-epileptics can cause the highest risk of teratogenicity?
A
Category 1
19
Q
Which anti-epileptic can cause cleft palate in the first trimester?
A
Topiramate
20
Q
Which anti-epileptic drugs are enzyme inducing, and hence effective contraception is needed?
A
(Remember CRAPPSS)
Carbamazepine
Phenytoin
Phenobarbital
21
Q
Why are newborns given a vitamin K injection once they are born?
A
To reduce the risk of neonatal haemorrhage
22
Q
Which anti-epileptic drugs are present in high amount in breast milk?
A
Remember ZELP
Zosinamide
Ethosuximide
Lamotrigine
Primidone
23
Q
Which 2 anti-epileptic drugs are at risk of accumulating in an infant if a mother is breastfeeding, and why?
A
Phenytoin and lamotrigine, because the infants metabolism is slower
24
Q
What are the symptoms of hypersensitivity syndrome associated with category 1 anti-epileptics within the first 1-8 weeks of starting treatment?
A
Rash
Fever
Lymphadenopathy
Systemic side effects
25
Which specific side effect should patients report if they are on any anti-epileptic?
Must report signs of suicidal behaviour/thought, or mood changes
26
Which anti-epileptic medications need to be reported if signs of infection/blood dyscrasias/bruising/bleeding occurs?
Remember C VET PLS
Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine
Zonisamide
27
Why should patients report signs of raised intra-ocular pressure with topiramate?
Because there is a risk of acute-closure glaucoma associated with topiramate
28
Which specific side effect are patients taking gabapentin mostly at risk of?
Risk of severe respiratory depression
29
Which anti-epileptic is an enzyme inhibitor?
Sodium valproate
30
What is the mechanism of action of phenytoin?
Binds to neuronal sodium channels and prolongs inactivity
31
What is the therapeutic plasma range of phenytoin?
10-20mg/L
32
Which form of phenytoin is its active form?
Free phenytoin (not when it is protein bound)
33
Why should clinicians monitor protein concentrations in a patient taking phenytoin?
Because phenytoin is highly protein bound, so patients with hypoalbuminaemia must be cautioned with as they have a risk of toxicity
34
What are the symptoms of phenytoin toxicity?
Remember SNAtCHED
Slurred speech
Nystagmus (eye rolling)
Ataxia (lack of muscle co-ordination)
Confusion
Hyperglycaemia
Diplopia (blurred vision)
35
Which form of phenytoin contains phenytoin sodium, and phenytoin base?
Tablets: phenytoin sodium
Liquid: phenytoin base
36
What are some side effects of phenytoin?
Coarsening of facial features
Acne
Gingivial hyperplasia
Rash (REPORT)
Infection/unexplained bruising (REPORT)
37
What are some symptoms associated with phenytoin induced hepato-toxicity?
Dark urine
Abdominal pain
Jaundice
Itchy skin
38
What parameters should be measured with phenytoin?
FBC
LFTs
ECG
BP
39
What is fosphenytoin and how is it given?
It is a prodrug of phenytoin which can be rapidly given IV or IM and has fewer site reactions compared to phenytoin
40
Which drugs can lower the seizure threshold when given with phenytoin?
TCAs
Tramadol
Quinolones
Mefloquine
41
What is the therapeutic range of carbamazepine and when are plasma levels measured?
4-12mg/L, measured 1-2 weeks after 1st dose
42
What are the symptoms of carbamazepine toxicity?
Inco-ordination
Ataxia
Nystagmus
Arrhythmia
Blurred vision
GI sid effects
43
What is their an increased risk of if carbamazepine is given with e.g. SSRIs, diuretics, NSAIDs or TCAs?
Hyponatraemia
44
How long is a prescription for sodium valproate valid for, and what is the max days of supply?
Prescription is valid for 7 days, and a max. of a 30 day supply is legally allowed.
45
What are examples of a highly effective contraception method as part of the PPP?
Either a copper IUD/sterilization, or use of 2 other forms e.g. barrier + pill
46
What symptoms should patients on sodium valproate report immediately?
Hepatotoxicity signs
Blood dyscrasias
Pancreatitis
47
What is status epilepticus and how is it managed?
It is a compete loss of consciousness + seizure lasting for >5 minutes.
Iv lorazepam is given
48
Which 2 benzodiazepines are short-acting?
Lorazepam and oxazepam
49
Which drugs are used to help with anxiety?
Benzodiazepines
Beta-blockers for e.g. palpitations
Buspirone
TCAS
50
How do benzodiazepines work?
They work by enhancing the binding of GABA to their receptors, hence increasing depressant/inhibitory effects
51
What are some side effects of benzodiazepines?
Hostility aggression
Overdose risk (resp. depression, coma)
Sedation
52
How should benzodiazepines be gradually withdrawn?
Equivalent dose of diazepam should be converted and titrated over.
53
What are the 1st and 2nd treatment options for ADHD?
1st: methylphenidate
2nd: lisdexamfetamine
54
What schedule drug is methylphenidate?
CD2
55
What are some side effects of methylphenidate?
Weight loss
Increased HR/BP
Growth restriction i children
56
Which condition is contraindicated for the use of most CD2 drugs?
CVD
57
What side effects can atomoxetine cause?
Suicidal ideation
Hepatotoxicity
QT prolongation
58
Which drugs are used to treat an acute episode of bipolar disorder?
Benzodiazepines
Antipsychotics - QOR (quetiapine, olanzapine, risperidone)
Haloperidol
59
What is the therapeutic range for lithium? What about during an acute manic episode?
0.4-1mmol/L normally
0.8-1mmol/L during an acute manic episode
60
How often should lithium plasma levels be measured?
12h after first dose or 1 week after dose changes, every 3 months for the 1st year, then every 6 months thereafter
61
What monitoring is required if a patient is taking lithium?
Renal function
TFTs
BMI
ECG
FBC
Electrolytes (esp. Na+)
62
What are the symptoms of lithium toxicity?
Renal impairment
Visual disturbances
CNS disturbances
GI side effects
63
What are some counselling points that should be mentioned to a patient taking lithium?
Report signs of hypothyroidism
Report signs of renal dysfunction
Report signs of benign intracranial hypertension
64
What can hyponatraemia cause in a patient taking lithium?
Can cause lithium toxicity
65
What should you always tell a patient who is taking lithium in terms of fluid and electrolytes?
Must maintain adequate salt/water intake, to avoid products with electrolytes e.g. dioralyte, and to always carry lithium alert card
66
Which drugs can prolong QT interval?
Amiodarone
Lithium
Quinolones
Macrolides
SSRIs
67
Why is imipramine avoided in patients with dementia?
Because it has the most anticholinergic properties
68
Why is fluoxetine recommended in younger people?
Because there is less risk for suicide
69
How long so SSRIs usually take to work?
At least 2 weeks
70
Why are MAO inhibitors rarely used for depression?
Because they have dangerous food/drug interactions
71
Which SSRI is safest to use in CVD patients?
Sertraline
72
What are some side effects of SSRIs?
Hyponatraemia
Suicidal ideation
Serotonin syndrome
73
How long should you wait before switching between different SSRIs?
Usually 1 week
(2 weeks if switching to sertraline, or 5 weeks for fluoxetine)
74
Over how many weeks should any antidepressant dose be reduced?
Dose should be reduced gradually over 4 weeks
75
Which 2 antidepressants have the highest risk of withdrawal reactions?
Paroxetine
Venlafaxine
76
Which 2 SSRIs cause QT prolongation?
Citalopram
Escitalopram
77
Which 2 neurotransmitters do TCAs inhibit the reuptake of?
5-HT (serotonin) and NA (noradrenaline)
78
What are some side effects of SSRIs?
Bleeding
QT interval prolongation
Lowered seizure threshold
Serotonin syndrome in high doses
79
What is the usual dose of TCAs?
Once daily at bedtime
80
What are some side effects of TCAs?
CV side effects e.g. QT prolongation, arrythmia
Antimuscarinic side effects
Seizures
Hypotension
81
Which MAO inhibitor has the most risk of causing hepatotoxicity?
Phenelzine
82
What other side effects are involved with the use of MAO inhibitors?
Postural hypotension
Hypertensive crisis - throbbing headaches
Hepatotoxicity
83
Which foods should people taking MAO inhibitors avoid?
Tyramine containing foods, e.g.
Mature cheese
Red wine
Game
Pickled herring
Alcohol
84
What occurs in the brain in schizophrenic patients?
Overactivity of dopamine in the mesolimbic pathway causing positive symptoms, and under-activity of the mesocortical pathway causing negative symptoms
85
Why should you avoid prescribing more than 1 antipsychotic in schizophrenic patients?
Because there is an increased risk of EPSE, CV events, and QT prolongation risk
86
Which 2nd generation antipsychotic is prescribed if >2 antipsychotics have not worked?
Clozapine
87
What type of antipsychotics are given during an acute emergency? What are some examples of these?
Short acting IM injections to induce rapid tranquillisation
Can include olanzapine, haloperidol, or zuclopenthixol
88
What should you do to the dose of anti-psychotics in elderly patients?
Reduce the adult dose by half
89
How often should antipsychotics be reviewed if used in a dementia patient?
At least every 6 weeks
90
What are 1st generation antipsychotics also known as?
Typicals
91
What side effects are associated with the use of 1st generation antipsychotics?
Extra pyramidal side effects
Hyperprolactinaemia
92
What are some examples of 1st generation antipsychotics?
Haloperidol
Chlorpromazine
Prochlorperazine
Flupentixol
93
Which 2 antipsychotics are most associated with QT prolongation?
Haloperidol
Quetiapine
94
What are 2nd generation antipsychotics also known as?
Atypicals
95
Which 2 2nd generation antipsychotics are most associated with hyperprolactinaemia?
Amisulpride
Risperidone
96
Which antipsychotic is not associated with hyperprolactinaemia?
Aripiprazole
97
Which 2 2nd generation antipsychotics are most associated with the most weight gain and diabetes?
Olanzapine
Clozapine
98
Why does hyperprolactinaemia occur with antipsychotics?
Because dopamine is associated with prolactin inhibition. Antipsychotics work by decreasing dopamine in the brain, hence causing high levels of prolactin
99
What is the 48h rule associated with clozapine?
If >2 doses of clozapine have been missed, then patient must go back to the GP to have their dose retitrated
100
What are patients taking clozapine most at risk of?
Agranulocytosis
Severe constipation/faecal impaction
Patients must report if one or both of these occur
101
What should you do to the dose of clozapine if the patient is a smoker?
Dose of clozapine needs to be higher as smoking is enzyme inducing
102
What monitoring is required with clozapine?
FBC/WBCs
Weight/BMI
LFTs
HbA1c
Lipid profile
Pulse/BP
Prolactin levels
Renal function
ECG
103
How often are depot antipsychotic injections given?
Every 1-4 weeks
104
Which antipsychotics can be given as a depot injection?
Paliperidone
Flupentixol
Zuclopentixol
Haloperidol
105
What should patients with schizophrenia have each year?
Physical health monitoring which includes a CVD risk assessment
106
What symptoms are involved in extra pyramidal side effects?
Parkinsons
Dystonia
Dyskinesia
Akathisia - restlessness
Tardive dyskinesia (reversible)
107
Which 2 antipsychotics are most associated with sexual dysfunction?
Haloperidol
Risperidone
108
What happens in the brain in a parkinsons patient?
Dopamine deficiency in the nigrostriatal pathway, causing excessive acetylcholine in the striatum
109
What are some symptoms of parkinsons disease?
Motor symptoms: rigidity, tremor, bradykinesia
Non-motor symptoms: dementia, depression, weight loss, speech problems
110
Why should you never abruptly stop parkinsons medication?
Because there is a risk of acute akinesia (loss of movement) and neuroleptic malignant syndrome
111
Which anti-emetic is recommended for use in Parkinsons disease?
Domperidone
112
How does levodopa containing medications work in a Parkinsons patient?
It is a precursor of dopamine which crosses the BBB and converts to dopamine
113
Why is levodopa sometimes given with benserazide or carbidopa?
To reduce peripheral breakdown of levodopa and reduce side effects like N&V
114
What are some examples of ergot derived dopamine agonists? Are these recommended?
Bromocriptine
Cabergoline
Not recommended due to risk of fibrotic reactions
115
What are some examples of non-ergot derived dopamine agonists?
Ropinirole
Amantadine
Rotigotine
116
Which MAO-B inhibitors are sometimes used in Parkinsons disease?
Rasagiline
Selegiline
117
What are some examples of COMT inhibitors that are used in Parkinsons disease?
Entacapone
Tolcapone
118
Which anti-parkinsonian drugs are used if motor symptoms do not affect quality of life?
Levodopa
Non-ergot derived - ropinirole, amantadine, rotigotine
MAO-B inhibitors - rasagiline, selegiline
119
What drug can be use din excessive drooling in Parkinsons?
Glycopyrronium bromide
120
What colour can entacapone colour urine?
Brownish orange
121
Which drug is used in advanced Parkinsons disease/'off' periods? How is this given?
Apomorphine SC or continuous infusion
122
What are the brands for levodopa + benserazide, and levodopa + carbidopa?
Levodopa + benserazide = co-beneldopa
Levodopa + carbidopa = co-careldopa
123
Why should levodopa containing Parkinson's drugs be taken at the same time everyday?
To avoid 'off' periods
124
What are some side effects of levodopa-containing Parkinson's drugs?
Impulsive behaviour - sex, gambling, eating
Excessive/sudden onset of sleep
Dyskinesia
'Off' periods = mobility weakness
End of dose deterioration (MR given to help with this)
125
What drug is given to Parkinson's patients for excessive sleep?
Modafinil
126
Which drugs are unlicensed in the use of postural hypotension associated with Parkinson's?
Midodrine
Fludrocortisone
127
Which side effects should patients report when taking ergot derived drugs like bromocriptine, or cabergoline?
Dyspnoea
SOB, wheezing
Abdominal pain
These could all be signs of fibrotic reactions
128
How do COMT inhibitors work?
They prevent the peripheral breakdown of levodopa by inhibiting the COMT enzyme, allowing more levodopa to reach the brain
129
What should patients taking tolcapone (a COMT inhibitor) report?
Signs of hepatotoxicity
130
What form of promethazine can be given in patients with persistent vomiting?
Buccal
131
Which anti-emetics can be used in chemotherapy?
Dexamethasone
5-HT3 antagonists, ending in -setron
132
Which anti-emetic can be used in palliative care?
Levomepromazine
133
Which anti-emetics can be used in pregnancy?
Prochlorperazine
Metoclopramide
134
Which anti emetic is best used in motion sickness?
Hyoscine bromide
135
What is the max. number of days which metoclopramide can be used, and why ?
5 days
To reduce the risk of tardive dyskinesia and EPSE
136
Why should metoclopramide not be used in over 18 years old?
Because there is a risk of acute dystonic reactions
137
What is the max. number of days which domperidone can be used?
1 week
138
Which side effects should patients taking domperidone immediately report?
Arrhythmia, syncope, palpitations
139
What age should domperidone be used?
Over 12 years old
140
Why should 5-HT3 antagonists be avoided in the 1st trimester of pregnancy?
Because there is a risk of cleft palate
141
What is classified as chronic pain?
If it has been present for more than 12 weeks
142
What should the dose of paracetamol be if a patient weights <50kg?
1g TDS
143
What are the doses of paracetamol for children (up to 5 years old) of a 120mg/5ml bottle?
3-5 months: 60mg
6-23 months: 120mg
2-3 years old: 180mg
4-5 years old: 240mg
144
What are the doses of paracetamol for children from 6+ years old from a 250/5ml bottle?
6-7 years old: 250mg
8-9 years old: 375mg
10-11years old: 500mg
145
Why is aspirin contraindicated in children under 16 years old?
Because it can cause Reyes syndrome
146
Which opioids are opioid agonists?
Heroin
Methadone
Morphine
Codeine
Fentanyl
147
Which opioid is a partial agonists?
Buprenorphine
148
Why does diamorphine have a quicker onset of action and less side effects than normal morphine?
Because diamorphine is water soluble, hence only small amounts are injected
149
What is the rescue fractional dose of morphine?
1/6 - 1/10th of the total morphine daily dose
150
What is the conversion from oral morphine to diamorphine?
Divide by 3
If from diamorphine to morphine, then x2 or x3 if severe
151
Which opioid antagonist is given to reverse an acute opioid overdose?
Naloxone
152
Which 2 laxatives are mainly given for opioid induced constipation?
A stimulant and osmotic
153
Which specific side effect is a major concern for all opioids?
Respiratory depression
154
What are some side effects of opioids?
Remember MORPHINE
Miosis (pinpoint pupils)
Out of it (sedation)
Respiratory depression
Postural hypotension
Hallucinations
Infrequency of urination
Nausea/vomiting
Euphoria
155
Which opioids are the longest acting, and hence can be used as patches?
Buprenorphine
Fentanyl
156
Why should you avoid direct heat to a fentanyl patch?
Because this can increase the absorption rate, leading to an increased risk of respiratory depression
157
What are some examples of weak opioids?
Tramadol
Codeine
Dihydrocodeine
158
Which genotype of patients should you avoid codeine in?
Ultra metabolisers or CYP2D6, because they are at risk of morphine toxicity
159
What is the max daily dose of codeine for 12-18 years old?
240mg daily
160
Why is codeine avoided in children <12 years old?
Because they are at more risk of respiratory side effects and morphine toxicity
161
What is a patient at risk of if they take tramadol and an SSRI?
Serotonin syndrome
162
Which specific group of drugs are used for migraines with aura, and when should they be taken?
5HT1 agonists (the triptans)
They must be taken at the start of the headache, not the aura
163
How long after can a -triptan be repeated after taking the first dose?
2h after
164
Which drugs can be used as prophylaxis for migraines?
B-blockers
Anti-epileptics
TCAs
Pizotifen
165
Which anti-emetics can be used for N+V during a migraine attack?
Metoclopramide
Domperidone
Anitihistamines
166
What drugs can be used for insomnia?
Z-drugs (zolpidem, zopiclone)
Benzodiazepines (diazepam, nitrazepam, temazepam)
167
What is narcolepsy?
Long-term brain disorder that causes a person to suddenly fall asleep
168
Which 2 drugs are used in assisted alcohol withdrawal?
Chlordiazepoxide, or diazepam
169
Which benzodiazepine is used in alcohol withdrawal seizures?
Lorazepam
170
Why must someone avoid alcohol while taking clomethiazole?
Because it can increase the risk of respiratory depression
171
Which drugs can be given for alcohol dependence (as treatment)?
Acamprostate
Naltrexone
Disulfram
172
What happens if a patient taking disulfram drinks alcohol?
Unpleasant systemic reaction, e.f. flushing N&V, tachycardia
173
What causes wernickes encephalopathy?
Thiamine (vit. B1) deficiency
174
How long should a patient avoid acidic drinks if they are taking buccal nicotine?
15mins after using the buccal nicotine as it can decrease the absorption rate if taken earlier
175
How long does it take for methadone to reach optimal levels in the body?
3-10 days (it has a long half life)
176
