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GPhC Exam Revison > Central Nervous System > Flashcards

Central Nervous System Flashcards

1
Q

What are the symptoms of dementia?

A

Memory loss
Difficult thinking
Psychiatric/behavioural problems
Language issues

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2
Q

What are the 3 acetylcholinesterase inhibitors used for mild-moderate alzheimers disease?

A
  1. Donepezil
  2. Galantamine
  3. Rivastigmine
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3
Q

Which acetylcholinesterase should be stopped at the firsts sign of a skin rash (SJS)?

A

Galantamine

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4
Q

Which drug is used in moderate-severe alzheimers disease?

A

Memantine

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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

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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

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7
Q

Which antipsychotics are recommended in dementia patients?

A

IM haloperidol, or risperidone
Olanzapine

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8
Q

Which anti-epileptics have a long half life, and are hence given ONCE a day?

A

Phenytoin
Lamotrigine
Perampanel
Phenobarbital

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9
Q

What are the 1st and 2nd line drug treatments for focal (partial seizures)?

A

1st: lamotrigine or levetiracetam
2nd: carbamazepine

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10
Q

What are the 1st and 2nd line treatment options for tonic-clonic seizures?

A

1st: valproate
2nd: lamotrigine, levetiracetam

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11
Q

What are the 1st and 2nd line treatment options for absence seizures?

A

1st: ethosuximide or valproate
2nd: lamotrigine

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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

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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

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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

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15
Q

What can sudden withdrawal of anti-epileptic drugs cause?

A

Severe rebound seizures

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16
Q

How long should epileptic patients not drive for if they have had an unprovoked or single isolated seizure?

A

6 months

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17
Q

How long should patients wait till they can drive again once they have been initially diagnosed?

A

1 year

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18
Q

Which category of anti-epileptics can cause the highest risk of teratogenicity?

A

Category 1

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19
Q

Which anti-epileptic can cause cleft palate in the first trimester?

A

Topiramate

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20
Q

Which anti-epileptic drugs are enzyme inducing, and hence effective contraception is needed?

A

(Remember CRAPPSS)

Carbamazepine
Phenytoin
Phenobarbital

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21
Q

Why are newborns given a vitamin K injection once they are born?

A

To reduce the risk of neonatal haemorrhage

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22
Q

Which anti-epileptic drugs are present in high amount in breast milk?

A

Remember ZELP

Zosinamide
Ethosuximide
Lamotrigine
Primidone

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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

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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

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25
Q

Which specific side effect should patients report if they are on any anti-epileptic?

A

Must report signs of suicidal behaviour/thought, or mood changes

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26
Q

Which anti-epileptic medications need to be reported if signs of infection/blood dyscrasias/bruising/bleeding occurs?

A

Remember C VET PLS

Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine
Zonisamide

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27
Q

Why should patients report signs of raised intra-ocular pressure with topiramate?

A

Because there is a risk of acute-closure glaucoma associated with topiramate

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28
Q

Which specific side effect are patients taking gabapentin mostly at risk of?

A

Risk of severe respiratory depression

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29
Q

Which anti-epileptic is an enzyme inhibitor?

A

Sodium valproate

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30
Q

What is the mechanism of action of phenytoin?

A

Binds to neuronal sodium channels and prolongs inactivity

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31
Q

What is the therapeutic plasma range of phenytoin?

A

10-20mg/L

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32
Q

Which form of phenytoin is its active form?

A

Free phenytoin (not when it is protein bound)

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33
Q

Why should clinicians monitor protein concentrations in a patient taking phenytoin?

A

Because phenytoin is highly protein bound, so patients with hypoalbuminaemia must be cautioned with as they have a risk of toxicity

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34
Q

What are the symptoms of phenytoin toxicity?

A

Remember SNAtCHED

Slurred speech
Nystagmus (eye rolling)
Ataxia (lack of muscle co-ordination)
Confusion
Hyperglycaemia
Diplopia (blurred vision)

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35
Q

Which form of phenytoin contains phenytoin sodium, and phenytoin base?

A

Tablets: phenytoin sodium
Liquid: phenytoin base

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36
Q

What are some side effects of phenytoin?

A

Coarsening of facial features
Acne
Gingivial hyperplasia
Rash (REPORT)
Infection/unexplained bruising (REPORT)

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37
Q

What are some symptoms associated with phenytoin induced hepato-toxicity?

A

Dark urine
Abdominal pain
Jaundice
Itchy skin

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38
Q

What parameters should be measured with phenytoin?

A

FBC
LFTs
ECG
BP

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39
Q

What is fosphenytoin and how is it given?

A

It is a prodrug of phenytoin which can be rapidly given IV or IM and has fewer site reactions compared to phenytoin

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40
Q

Which drugs can lower the seizure threshold when given with phenytoin?

A

TCAs
Tramadol
Quinolones
Mefloquine

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41
Q

What is the therapeutic range of carbamazepine and when are plasma levels measured?

A

4-12mg/L, measured 1-2 weeks after 1st dose

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42
Q

What are the symptoms of carbamazepine toxicity?

A

Inco-ordination
Ataxia
Nystagmus
Arrhythmia
Blurred vision
GI sid effects

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43
Q

What is their an increased risk of if carbamazepine is given with e.g. SSRIs, diuretics, NSAIDs or TCAs?

A

Hyponatraemia

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44
Q

How long is a prescription for sodium valproate valid for, and what is the max days of supply?

A

Prescription is valid for 7 days, and a max. of a 30 day supply is legally allowed.

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45
Q

What are examples of a highly effective contraception method as part of the PPP?

A

Either a copper IUD/sterilization, or use of 2 other forms e.g. barrier + pill

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46
Q

What symptoms should patients on sodium valproate report immediately?

A

Hepatotoxicity signs
Blood dyscrasias
Pancreatitis

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47
Q

What is status epilepticus and how is it managed?

A

It is a compete loss of consciousness + seizure lasting for >5 minutes.

Iv lorazepam is given

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48
Q

Which 2 benzodiazepines are short-acting?

A

Lorazepam and oxazepam

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49
Q

Which drugs are used to help with anxiety?

A

Benzodiazepines
Beta-blockers for e.g. palpitations
Buspirone
TCAS

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50
Q

How do benzodiazepines work?

A

They work by enhancing the binding of GABA to their receptors, hence increasing depressant/inhibitory effects

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51
Q

What are some side effects of benzodiazepines?

A

Hostility aggression
Overdose risk (resp. depression, coma)
Sedation

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52
Q

How should benzodiazepines be gradually withdrawn?

A

Equivalent dose of diazepam should be converted and titrated over.

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53
Q

What are the 1st and 2nd treatment options for ADHD?

A

1st: methylphenidate
2nd: lisdexamfetamine

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54
Q

What schedule drug is methylphenidate?

A

CD2

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55
Q

What are some side effects of methylphenidate?

A

Weight loss
Increased HR/BP
Growth restriction i children

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56
Q

Which condition is contraindicated for the use of most CD2 drugs?

A

CVD

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57
Q

What side effects can atomoxetine cause?

A

Suicidal ideation
Hepatotoxicity
QT prolongation

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58
Q

Which drugs are used to treat an acute episode of bipolar disorder?

A

Benzodiazepines
Antipsychotics - QOR (quetiapine, olanzapine, risperidone)
Haloperidol

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59
Q

What is the therapeutic range for lithium? What about during an acute manic episode?

A

0.4-1mmol/L normally
0.8-1mmol/L during an acute manic episode

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60
Q

How often should lithium plasma levels be measured?

A

12h after first dose or 1 week after dose changes, every 3 months for the 1st year, then every 6 months thereafter

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61
Q

What monitoring is required if a patient is taking lithium?

A

Renal function
TFTs
BMI
ECG
FBC
Electrolytes (esp. Na+)

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62
Q

What are the symptoms of lithium toxicity?

A

Renal impairment
Visual disturbances
CNS disturbances
GI side effects

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63
Q

What are some counselling points that should be mentioned to a patient taking lithium?

A

Report signs of hypothyroidism
Report signs of renal dysfunction
Report signs of benign intracranial hypertension

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64
Q

What can hyponatraemia cause in a patient taking lithium?

A

Can cause lithium toxicity

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65
Q

What should you always tell a patient who is taking lithium in terms of fluid and electrolytes?

A

Must maintain adequate salt/water intake, to avoid products with electrolytes e.g. dioralyte, and to always carry lithium alert card

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66
Q

Which drugs can prolong QT interval?

A

Amiodarone
Lithium
Quinolones
Macrolides
SSRIs

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67
Q

Why is imipramine avoided in patients with dementia?

A

Because it has the most anticholinergic properties

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68
Q

Why is fluoxetine recommended in younger people?

A

Because there is less risk for suicide

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69
Q

How long so SSRIs usually take to work?

A

At least 2 weeks

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70
Q

Why are MAO inhibitors rarely used for depression?

A

Because they have dangerous food/drug interactions

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71
Q

Which SSRI is safest to use in CVD patients?

A

Sertraline

72
Q

What are some side effects of SSRIs?

A

Hyponatraemia
Suicidal ideation
Serotonin syndrome

73
Q

How long should you wait before switching between different SSRIs?

A

Usually 1 week
(2 weeks if switching to sertraline, or 5 weeks for fluoxetine)

74
Q

Over how many weeks should any antidepressant dose be reduced?

A

Dose should be reduced gradually over 4 weeks

75
Q

Which 2 antidepressants have the highest risk of withdrawal reactions?

A

Paroxetine
Venlafaxine

76
Q

Which 2 SSRIs cause QT prolongation?

A

Citalopram
Escitalopram

77
Q

Which 2 neurotransmitters do TCAs inhibit the reuptake of?

A

5-HT (serotonin) and NA (noradrenaline)

78
Q

What are some side effects of SSRIs?

A

Bleeding
QT interval prolongation
Lowered seizure threshold
Serotonin syndrome in high doses

79
Q

What is the usual dose of TCAs?

A

Once daily at bedtime

80
Q

What are some side effects of TCAs?

A

CV side effects e.g. QT prolongation, arrythmia
Antimuscarinic side effects
Seizures
Hypotension

81
Q

Which MAO inhibitor has the most risk of causing hepatotoxicity?

A

Phenelzine

82
Q

What other side effects are involved with the use of MAO inhibitors?

A

Postural hypotension
Hypertensive crisis - throbbing headaches
Hepatotoxicity

83
Q

Which foods should people taking MAO inhibitors avoid?

A

Tyramine containing foods, e.g.
Mature cheese
Red wine
Game
Pickled herring
Alcohol

84
Q

What occurs in the brain in schizophrenic patients?

A

Overactivity of dopamine in the mesolimbic pathway causing positive symptoms, and under-activity of the mesocortical pathway causing negative symptoms

85
Q

Why should you avoid prescribing more than 1 antipsychotic in schizophrenic patients?

A

Because there is an increased risk of EPSE, CV events, and QT prolongation risk

86
Q

Which 2nd generation antipsychotic is prescribed if >2 antipsychotics have not worked?

A

Clozapine

87
Q

What type of antipsychotics are given during an acute emergency? What are some examples of these?

A

Short acting IM injections to induce rapid tranquillisation

Can include olanzapine, haloperidol, or zuclopenthixol

88
Q

What should you do to the dose of anti-psychotics in elderly patients?

A

Reduce the adult dose by half

89
Q

How often should antipsychotics be reviewed if used in a dementia patient?

A

At least every 6 weeks

90
Q

What are 1st generation antipsychotics also known as?

A

Typicals

91
Q

What side effects are associated with the use of 1st generation antipsychotics?

A

Extra pyramidal side effects
Hyperprolactinaemia

92
Q

What are some examples of 1st generation antipsychotics?

A

Haloperidol
Chlorpromazine
Prochlorperazine
Flupentixol

93
Q

Which 2 antipsychotics are most associated with QT prolongation?

A

Haloperidol
Quetiapine

94
Q

What are 2nd generation antipsychotics also known as?

A

Atypicals

95
Q

Which 2 2nd generation antipsychotics are most associated with hyperprolactinaemia?

A

Amisulpride
Risperidone

96
Q

Which antipsychotic is not associated with hyperprolactinaemia?

A

Aripiprazole

97
Q

Which 2 2nd generation antipsychotics are most associated with the most weight gain and diabetes?

A

Olanzapine
Clozapine

98
Q

Why does hyperprolactinaemia occur with antipsychotics?

A

Because dopamine is associated with prolactin inhibition. Antipsychotics work by decreasing dopamine in the brain, hence causing high levels of prolactin

99
Q

What is the 48h rule associated with clozapine?

A

If >2 doses of clozapine have been missed, then patient must go back to the GP to have their dose retitrated

100
Q

What are patients taking clozapine most at risk of?

A

Agranulocytosis
Severe constipation/faecal impaction

Patients must report if one or both of these occur

101
Q

What should you do to the dose of clozapine if the patient is a smoker?

A

Dose of clozapine needs to be higher as smoking is enzyme inducing

102
Q

What monitoring is required with clozapine?

A

FBC/WBCs
Weight/BMI
LFTs
HbA1c
Lipid profile
Pulse/BP
Prolactin levels
Renal function
ECG

103
Q

How often are depot antipsychotic injections given?

A

Every 1-4 weeks

104
Q

Which antipsychotics can be given as a depot injection?

A

Paliperidone
Flupentixol
Zuclopentixol
Haloperidol

105
Q

What should patients with schizophrenia have each year?

A

Physical health monitoring which includes a CVD risk assessment

106
Q

What symptoms are involved in extra pyramidal side effects?

A

Parkinsons
Dystonia
Dyskinesia
Akathisia - restlessness
Tardive dyskinesia (reversible)

107
Q

Which 2 antipsychotics are most associated with sexual dysfunction?

A

Haloperidol
Risperidone

108
Q

What happens in the brain in a parkinsons patient?

A

Dopamine deficiency in the nigrostriatal pathway, causing excessive acetylcholine in the striatum

109
Q

What are some symptoms of parkinsons disease?

A

Motor symptoms: rigidity, tremor, bradykinesia

Non-motor symptoms: dementia, depression, weight loss, speech problems

110
Q

Why should you never abruptly stop parkinsons medication?

A

Because there is a risk of acute akinesia (loss of movement) and neuroleptic malignant syndrome

111
Q

Which anti-emetic is recommended for use in Parkinsons disease?

A

Domperidone

112
Q

How does levodopa containing medications work in a Parkinsons patient?

A

It is a precursor of dopamine which crosses the BBB and converts to dopamine

113
Q

Why is levodopa sometimes given with benserazide or carbidopa?

A

To reduce peripheral breakdown of levodopa and reduce side effects like N&V

114
Q

What are some examples of ergot derived dopamine agonists? Are these recommended?

A

Bromocriptine
Cabergoline

Not recommended due to risk of fibrotic reactions

115
Q

What are some examples of non-ergot derived dopamine agonists?

A

Ropinirole
Amantadine
Rotigotine

116
Q

Which MAO-B inhibitors are sometimes used in Parkinsons disease?

A

Rasagiline
Selegiline

117
Q

What are some examples of COMT inhibitors that are used in Parkinsons disease?

A

Entacapone
Tolcapone

118
Q

Which anti-parkinsonian drugs are used if motor symptoms do not affect quality of life?

A

Levodopa
Non-ergot derived - ropinirole, amantadine, rotigotine
MAO-B inhibitors - rasagiline, selegiline

119
Q

What drug can be use din excessive drooling in Parkinsons?

A

Glycopyrronium bromide

120
Q

What colour can entacapone colour urine?

A

Brownish orange

121
Q

Which drug is used in advanced Parkinsons disease/’off’ periods? How is this given?

A

Apomorphine SC or continuous infusion

122
Q

What are the brands for levodopa + benserazide, and levodopa + carbidopa?

A

Levodopa + benserazide = co-beneldopa

Levodopa + carbidopa = co-careldopa

123
Q

Why should levodopa containing Parkinson’s drugs be taken at the same time everyday?

A

To avoid ‘off’ periods

124
Q

What are some side effects of levodopa-containing Parkinson’s drugs?

A

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
Q

What drug is given to Parkinson’s patients for excessive sleep?

A

Modafinil

126
Q

Which drugs are unlicensed in the use of postural hypotension associated with Parkinson’s?

A

Midodrine
Fludrocortisone

127
Q

Which side effects should patients report when taking ergot derived drugs like bromocriptine, or cabergoline?

A

Dyspnoea
SOB, wheezing
Abdominal pain

These could all be signs of fibrotic reactions

128
Q

How do COMT inhibitors work?

A

They prevent the peripheral breakdown of levodopa by inhibiting the COMT enzyme, allowing more levodopa to reach the brain

129
Q

What should patients taking tolcapone (a COMT inhibitor) report?

A

Signs of hepatotoxicity

130
Q

What form of promethazine can be given in patients with persistent vomiting?

A

Buccal

131
Q

Which anti-emetics can be used in chemotherapy?

A

Dexamethasone
5-HT3 antagonists, ending in -setron

132
Q

Which anti-emetic can be used in palliative care?

A

Levomepromazine

133
Q

Which anti-emetics can be used in pregnancy?

A

Prochlorperazine
Metoclopramide

134
Q

Which anti emetic is best used in motion sickness?

A

Hyoscine bromide

135
Q

What is the max. number of days which metoclopramide can be used, and why ?

A

5 days
To reduce the risk of tardive dyskinesia and EPSE

136
Q

Why should metoclopramide not be used in over 18 years old?

A

Because there is a risk of acute dystonic reactions

137
Q

What is the max. number of days which domperidone can be used?

A

1 week

138
Q

Which side effects should patients taking domperidone immediately report?

A

Arrhythmia, syncope, palpitations

139
Q

What age should domperidone be used?

A

Over 12 years old

140
Q

Why should 5-HT3 antagonists be avoided in the 1st trimester of pregnancy?

A

Because there is a risk of cleft palate

141
Q

What is classified as chronic pain?

A

If it has been present for more than 12 weeks

142
Q

What should the dose of paracetamol be if a patient weights <50kg?

A

1g TDS

143
Q

What are the doses of paracetamol for children (up to 5 years old) of a 120mg/5ml bottle?

A

3-5 months: 60mg
6-23 months: 120mg
2-3 years old: 180mg
4-5 years old: 240mg

144
Q

What are the doses of paracetamol for children from 6+ years old from a 250/5ml bottle?

A

6-7 years old: 250mg
8-9 years old: 375mg
10-11years old: 500mg

145
Q

Why is aspirin contraindicated in children under 16 years old?

A

Because it can cause Reyes syndrome

146
Q

Which opioids are opioid agonists?

A

Heroin
Methadone
Morphine
Codeine
Fentanyl

147
Q

Which opioid is a partial agonists?

A

Buprenorphine

148
Q

Why does diamorphine have a quicker onset of action and less side effects than normal morphine?

A

Because diamorphine is water soluble, hence only small amounts are injected

149
Q

What is the rescue fractional dose of morphine?

A

1/6 - 1/10th of the total morphine daily dose

150
Q

What is the conversion from oral morphine to diamorphine?

A

Divide by 3

If from diamorphine to morphine, then x2 or x3 if severe

151
Q

Which opioid antagonist is given to reverse an acute opioid overdose?

A

Naloxone

152
Q

Which 2 laxatives are mainly given for opioid induced constipation?

A

A stimulant and osmotic

153
Q

Which specific side effect is a major concern for all opioids?

A

Respiratory depression

154
Q

What are some side effects of opioids?

A

Remember MORPHINE

Miosis (pinpoint pupils)
Out of it (sedation)
Respiratory depression
Postural hypotension
Hallucinations
Infrequency of urination
Nausea/vomiting
Euphoria

155
Q

Which opioids are the longest acting, and hence can be used as patches?

A

Buprenorphine
Fentanyl

156
Q

Why should you avoid direct heat to a fentanyl patch?

A

Because this can increase the absorption rate, leading to an increased risk of respiratory depression

157
Q

What are some examples of weak opioids?

A

Tramadol
Codeine
Dihydrocodeine

158
Q

Which genotype of patients should you avoid codeine in?

A

Ultra metabolisers or CYP2D6, because they are at risk of morphine toxicity

159
Q

What is the max daily dose of codeine for 12-18 years old?

A

240mg daily

160
Q

Why is codeine avoided in children <12 years old?

A

Because they are at more risk of respiratory side effects and morphine toxicity

161
Q

What is a patient at risk of if they take tramadol and an SSRI?

A

Serotonin syndrome

162
Q

Which specific group of drugs are used for migraines with aura, and when should they be taken?

A

5HT1 agonists (the triptans)
They must be taken at the start of the headache, not the aura

163
Q

How long after can a -triptan be repeated after taking the first dose?

A

2h after

164
Q

Which drugs can be used as prophylaxis for migraines?

A

B-blockers
Anti-epileptics
TCAs
Pizotifen

165
Q

Which anti-emetics can be used for N+V during a migraine attack?

A

Metoclopramide
Domperidone
Anitihistamines

166
Q

What drugs can be used for insomnia?

A

Z-drugs (zolpidem, zopiclone)
Benzodiazepines (diazepam, nitrazepam, temazepam)

167
Q

What is narcolepsy?

A

Long-term brain disorder that causes a person to suddenly fall asleep

168
Q

Which 2 drugs are used in assisted alcohol withdrawal?

A

Chlordiazepoxide, or diazepam

169
Q

Which benzodiazepine is used in alcohol withdrawal seizures?

A

Lorazepam

170
Q

Why must someone avoid alcohol while taking clomethiazole?

A

Because it can increase the risk of respiratory depression

171
Q

Which drugs can be given for alcohol dependence (as treatment)?

A

Acamprostate
Naltrexone
Disulfram

172
Q

What happens if a patient taking disulfram drinks alcohol?

A

Unpleasant systemic reaction, e.f. flushing N&V, tachycardia

173
Q

What causes wernickes encephalopathy?

A

Thiamine (vit. B1) deficiency

174
Q

How long should a patient avoid acidic drinks if they are taking buccal nicotine?

A

15mins after using the buccal nicotine as it can decrease the absorption rate if taken earlier

175
Q

How long does it take for methadone to reach optimal levels in the body?

A

3-10 days (it has a long half life)

176
Q
A

GPhC Exam Revison (5 decks)

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