Central Nervous System Flashcards
What are the different types of dementia?
Alzheimer’s, vascular, Lewy body, mixed, frontotemporal
What is the most common type of dementia?
Alzheimer’s
How do we treat the cognitive symptoms of Alzheimer’s disease?
First line: Anticholinesterase inhibitor monotherapy: e.g. donepezil, rivastigmine or galantamine.
Second line memantine
How do we treat cognitive symptoms of non-Alzheimer’s dementia?
Do monotherapy with acetylcholinesterase inhibitors like donepezil or rivastigmine (all unlicensed) but use galantamine only if the first two aren’t tolerated
When do you treat the cognitive symptoms of vascular disease?
Only when they have co-morbidities such as Alzheimer’s disease, Parkinson’s or lewy body dementia
What class of drug in Memantine?
NMDA receptor antagonist
What is the MHRA warning with giving antipsychotics to dementia patients?
Increased risk of stroke and small increase of risk of death in patients who have dementia
When do we give antipsychotics to patients with dementia?
ONLY if they are at risk of harming themselves or others/having crazy wild mental delusions (poor huns) (review every 6 weeks)
What is rivastigmine also used to treat?
Parkinson’s disease
Side effect of galantamine?
Serious skin reaction- stop medicine
Side effects of rivastigmine?
Weight loss
What is the first line for cognitive symptoms in moderate Alzheimer’s?
Memantine
Side effect of memantine
Can cause convulsions
Are acetylcholinesterase inhibitors or memantine recommended in patients with frontotemporal dementia or cognitive impairment associated with multiple sclerosis?
No
How do you treat aggression in dementia patients?
Benzodiazepines, antipsychotics (only if worth it)
List some CHOLINERGIC side effects
Diarrhoea, urination, muscle weakness, bronchospasm, bradycardia (opposite of anticholinergics), saltivation, sweating, emesis, lacrimation (teary eyes)
Which antiepileptics can you take once daily as they have a longer half-life?
Perampanel, lamotrigine, phenytoin, phenobarbitone
Which antiepileptics are in category 1 (advised to maintain on same product)?
Carbamazepine, phenytoin, phenobarbitone, primidone
Which antiepileptics are in category 2 (based on clinical judgement and patient consultation)?
Valporate, amotrigine, clonazepam, topiramate
Which antiepileptics are in category 3 (do not need to maintain on same product)?
levetiracetam, gabapentin, pregablin, ethosuximide
Which is first line for tonic-clonic seizures?
Valproate or lamotrigine
Which is first line for partial/focal seizures?
Lamotrigine or carbamazepine
Which is first line for myoclonic seizures?
Valproate
Which is first line for atonic/tonic seizures?
Valproate or lamotrigine
Which is first line for absence seizures?
Ethosuximide or valproate
What is antiepileptic hypersensitivity syndrome?
A potentially fatal syndrome which occurs within 1-8 weeks of exposure of antiepileptics, it causes a rash, haem, multi organ failure, liver, renal fever etc. Drug should be withdrawn immediately but avoid abrupt withdrawal- GRADUAL as can cause withdrawal seizure even if seizure free for years. Patient must not be re-exposed.
What is the MHRA warning with antiepileptic drugs?
There is a small risk of suicidal thoughts and depression, symptoms may occur up to one week after starting the treatment
How long must a patient wait to start driving again (VW Golf lol) if they have had an unprovoked seizure? (not epileptic)
6 months
How long must a patient be seizure free if they have epilepsy?
1 year (NB: patients can also do this if they have an established seizure pattern where it doesn’t affect their consciousness, they must also have no history of unprovoked seizures- 1 year but 3 years for established asleep attacks without awake attacks but also history of no awake seizures for 1 year)
Which vehicles can epileptics not drive?
Large goods or passenger carrying vehicle
List some drugs which lower the seizure threshold
Quinolones, carbapenems, SSRIs, TCAs, antipsychotics, tramadol, methadone
How long does the driving ban last when doses etc of anti-epileptics are changed?
6 months after last dose and DURING medication dose changes or withdrawal
Which anti-epileptics are present in high amounts in breast milk?
Ethosuximide, zonisamide, lamotrigine, primidone (ZELP)
Which anti-epileptics are associated with drowsiness with the infant?
Phenytoin and phenobarbitone and benzodiazepines
Which anti-epileptic gives the highest risk to the baby when Mum is pregnant?
Sodium valproate (30-40% developmental disorders)
Which other anti-epileptics are associated with increased teratogenicity?
Phenytoin, primidone, phenobarbital, lamotrigine, topiramate and carbamazepine
Which anti-epileptic has increased risk of congenital malformations i.e., cleft palate?
Topiramate
What do we give to reduce the risk of neural tube defects?
Folic acid 5mg OD during conception and throughout first trimester
Which anti-epileptics are considered to be the safest in pregnancy?
Levetiracetam and lamotrigine
Which doses should be changed during pregnancy if a patient is already on this anti-epileptic?
Lamotrigine, phenytoin, carbamazepine – base on drug-plasma concentration
Which drugs do we measure foetal growth with?
Levetiracetam and topiramate
What is the MOA of phenytoin?
It binds to neuronal sodium channels in their inactive state, prolonging inactivity
What type of seizures does phenytoin exacerbate?
Myoclonic and absence seizures
What is the therapeutic range for phenytoin?
10-20mg/L
Is there a linear or non-linear relationship between phenytoin and its concentration?
Non- linear (small changes in dose/missed doses/absorption can = large changes in concentration because phenytoin is a highly protein bound drug. When protein binding is reduced, monitor the free plasma concentration, this changes in pregnancy, children, elderly and liver failure. These three groups easily show signs of toxicity.
What is the patient safety alert with phenytoin?
The use of injectable phenytoin is error-prone through prescribing, preparation, administration and monitoring processes. All relevant staff should be made aware there is a HIGH risk of death and severe harm from error.
What are the signs and symptoms of toxicity for phenytoin?
SNAtCHeD:
Slurred speech
Nystagmus
Ataxia (lack of voluntary moving and co-ordination of muscle movement), confusion,
Hyperglycaemia,
Diplopia (double vision) and Blurred vision
What are the side effects of phenytoin?
Gingival hyperplasia, thickening/coarsening of facial features, acne, blood dyscrasias (watch out for signs of infection), hypersensitivity (antiepileptic hypersensitivity syndrome), rashes, low vit D (as induced vit D metabolism), hepatotoxicity, suicidal ideation
MOA of carbamazepine
Inhibits neuronal sodium channels and stabilises membrane potential and reduces neuronal excitability.
What types of seizures do carbamazepine exacerbate?
Atonic, clonic and myoclonic
What is the therapeutic range of carbamazepine?
4-12mg/L
When do you monitor the therapeutic range of carbamazepine?
1 to 2 weeks after
What are the signs of carbamazepine toxicity?
I-HANDBAG:
in-coordination, Hyponatraemia,
Ataxia,
Nystagmus,
Drowsiness,
Blurred vision and diplopia,
Arrhythmias,
Gastrointestinal disturbance (N+V+D)
What are the side effects of carbamazepine?
Blood dyscrasias (monitor signs of infection), hepatotoxicity, antiepileptic hypersensitivity syndrome, rash, hyponatraemia
List some interactions with carbamazepine?
Enzyme inducers (CRAPGPS), enzyme inhibitors (SICKFACES.COM), further
hyponatraemia (PPIs, diuretics, SSRIs, TCAs, NSAIDs),
decreased seizure threshold
(quinolones, SSRIs, TCAs, macrolides, tramadol, methadone, mefloquine),
increased risk of hepatotoxicity (isoniazid, fluconazole, alcohol, statins, tetracyclines, methotrexate),
as carbamazepine is a CYP450 inducer itself, it reduces the conc of warfarin, contraceptives etc
What kind of contraception are you allowed with PPP?
If using user independent methods, 1 of: IUD, POP implant, sterilization. If user dependent: COC+ barrier + regular pregnancy test
What are the patient materials for risk minimisation support materials?
Patient alert card, patient leaflet, patient guide, annual risk acknowledgement form
Every time a pharmacist dispenses sodium valproate to a female, what must they do/provide?
Valproate patient card, reminder of risks in pregnancy and need for highly effective contraception, ensure annual review and need for it, dispense whole original pack, all packs must have warning label on or sticker, the PIL, ensure they have read the patient guide, if a patient is NOT taking highly effective contraception – refer to GP
What are the side effects of sodium valproate?
Hepatotoxicity, pancreatitis, blood dyscrasias
What is status epilepticus?
Continuous seizures lasting longer than 5 minutes
What is the treatment for status epilepticus?
Oxygen if needed, thiamine if alcohol induced, position to avoid injury, maintain BP and correction of any hypoglycaemia… IV LORAZEPAM (repeat once after 10 mins if fails). Although diazepam can administered via rectal solution or midazolam oromucosal solution- buccal cavity.
If seizures fail to stop after 25 minutes, phenytoin/fosphenytoin should be used and contact ITU if seizures continue>
If after 45 mins, anaesthesia with thiopental or midazolam or propofol with full ITU support.
Why do we use IV lorazepam over diazepam?
Diazepam has a risk of thrombophlebitis IV, PR (suppositories) or IM is too slowly absorbed for efficacy.
How do you treat febrile convulsions?
Paracetamol, if >5 treat as status epilepticus
Who do we avoid lamotrigine in?
Parkinson’s disease and myoclonic seizure patients
What class of CD is gabapentin?
Schedule 3
What is the MHRA alert with gabapentin?
Risk of respiratory depression
Side effects of topiramate
acute myopia (short sightedness) with secondary angle glaucoma
What class of CD’s are benzodiazepine’s?
CD4 part I
Which Benzodiazepine is longer acting and which is shorter acting out of lorazepam and diazepam?
Diazepam is longer acting, and lorazepam is shorter acting
What is the elderly STOPP criteria? (prescription potentially inappropriate)
A duration of 4 weeks or longer, if with acute or chronic respiratory failure, patients prone to falls
What is ADHD?
Attention deficit hyperactivity disorder, characterised by: hyperactivity, impulsivity, inattention
First line treatment for ADHD?
Lisdexamfetamine or methylphenidate, if one not work switch to another in 6 weeks (NB: dexamfetamine can be trialled if patients having beneficial effect to lisdexamfetamine but cannot tolerate longer duration of effect – unlicensed)
second line: atomoxetine
What are the side effects of atomoxetine?
Sexual dysfunction, changes in sleeping patterns
What class of drug is methylphenidate?
Class 2
What are the side effects of methylphenidate?
Growth restriction in children, appetite loss, insomnia, tachycardia and hypertension, tics and tourette’s syndrome
What do you monitor with methylphenidate?
Blood pressure and pulse (as causes HTN and tachycardia), height and weight (as causes growth restriction), psychiatric symptoms eg depression, psychosis and suidal ideation
How do you prescribe methylphenidate? (formulation wise)
By modified release brand preparations
Regarding antipsychotics, how often can you change the dose?
Maximum once weekly
Generally, with antipsychotics, do they help positive or negative symptoms?
Positive symptoms i.e. hallucinations, thought disorder, delusions
How do first generation antipsychotics work?
By blocking the dopamine D2 receptors in the brain
What does EPSE stand for? What are they?
Extrapyramidal side effects: PDAT =parkinsonism (tremor), dystonia (weird body/face movements), akathisia (restlessness), tardive dyskinesia (rhythmic involuntary movements of face, tongue and jaw
What other side effects do antipsychotics have?
Hyperprolactinaemia, sexual dysfunction, CV effects, hyperglycaemia and weight gain, hypotension and interference with temp regulation, neuroleptic malignant syndrome, blood dyscrasias
Give some examples of second-generation antipsychotics
Clozapine, olanzapine, quetiapine, risperidone, aripirazole
Are first gen or second generation more likely to cause EPSE?
First generation
Which generation antipsychotics are more likely to cause metabolic side effects?
Second generation
Which generation of antipsychotics have a better effect on negative symptoms?
Second generation
What do you do to the dosage of antipsychotics with elderly patients with dementia?
Halve the dosage due to risk of stroke and death
Why do antipsychotics cause hyperprolactinaemia?
Because they reduce dopamine levels and dopamine inhibits prolactin
Which is the only antipsychotic that reduces prolactin levels and why?
Aripiprazole because it is a partial dopamine agonist also, so more levels of dopamine = higher inhibition of prolactin = lower levels
What are the MHRA alerts with clozapine?
Monitor blood concentrations for toxicity, potentially fatal risk in intestinal obstruction or faecal impaction and paralytic ileus. NB: myocarditis cautioned in clozapine
What monitoring is required with clozapine?
Leucocytes every week for 18 weeks, then fortnightly for up to a year, then monthly.
Blood lipids and weight at baseline, 3 months, then 12 months
Fasting BMs at baseline, 4-6 monthly, then 12 months then yearly
Hepatic function regularly
BP during initiation
When is clozapine initiated?
When unresponsive to 2 antipsychotics have not worked for 6-8 weeks
What is the monitoring for all antipsychotics?
FBC, U+Es, LFTs, glucose initiation and annually,
weight and lipids baseline, 3 months, then yearly,
ECG before initiation, BP before starting and with any dose changes,
prolactin initiation, 6 months then yearly
If a patient has been on long term antipsychotics (especially clozapine), there is a high risk of relapse if stopped. How do you reduce this?
Gradual withdrawal, monitor for 2 years after withdrawal
What are the symptoms of neuroleptic malignant syndrome?
High fever, confusion, variable BP, HR, ridged muscles
How do you treat acute episodes of bipolar?
A) Initial stages – BZs but don’t use for long periods
B) antipsychotic drugs (olanzapine, quetiapine or risperidone)
C) Lithium or valproate if inadequate response (+/- antipsychotic)
Long term therapy generally: Olanzapine (+/- lithium or valproate) if patient has frequent relapse/continuing functional impairment.
Carbamazepine can be used but ONLY in specialist situations where there is RAPID cycling manic depressions (4 or more affective episodes a year)
What do you do if someone is to have antipsychotics discontinued?
Withdraw over 4 weeks, dose reduce gradually IF THE PATIENT IS CONTINUING WITH OTHER ANTIMANIC DRUGS. If patient is not continuing with other antimanic drugs or if history of manic relapse have a withdrawal period of up to 3 months
How long can it take for lithium to work/have an effect?
6 months to 12 months
What is the narrow therapeutic range for lithium?
0.4-1mmol/L normally and 0.8-1mmol/L in mania patients
What is a lifestyle point that needs to be told to the patient when initiating lithium?
Maintain adequate hydration and salt intake (as toxicity is worsened by sodium depletion)
Lithium toxicity signs?
Seizures, coma, renal failure, arrythmias, BP changes, circulatory failure, death, polyuria, polydipsia, muscle weakness, confusion
What do you monitor with lithium toxicity and when?
Serum lithium concentration weekly until stable, then every 3/12, renal, thyroid and cardiac every 6 months
What colour is the lithium book?
Purple
What is the interaction between amiodarone and lithium?
Risk of ventricular arrhythmias increase with amiodarone and lithium
What is the interaction between methyldopa with lithium?
Increased risk of neurotoxicity (same with diltiazem and verapamil and carbamazepine)
List some MAOIs
moclobemide, tranylcypromine, isocarboxazid
List some TCAs
Amitriptyline, clomipramine, dosulepin (dangerous in overdose), imipramine (more antimuscarinic) etc
What class of drug is duloxetine?
SNRI
Which is the only SSRI that is given to children?
Fluoxetine
Which SSRI is safe to use in MI/unstable angina?
Sertraline
In depression, if you do not respond to an SSRI, what is second line?
A) switch to another SSRI or
B) increase dose
C) use mirtazapine Third line= add TCA
How long do you have to leave before starting new antidepressive treatment after discontinuing MAOIs?
2 weeks
How long do you have to leave before starting new antidepressive treatment after discontinuing TCAs?
7-14 days (3 weeks for imipramine or clomipramine)
How long do you have to leave before starting new antidepressive treatment after discontinuing SSRIs?
A week , but 5 weeks for fluoxetine, 2 weeks sertraline
How often should a patient be reviewed when starting antidepressants?
Every 1-2 weeks at the start of Tx, continue for at least four weeks BUT six weeks in elderly, in partial response continue for another 1-2 weeks. Following remission, patients should have the same dose Tx for 6 months but 12 months in elderly
Which class of antidepressants is hyponatraemia more prominent in?
SSRIs
What are the characteristics of serotonin syndrome?
Twitching, clonus, rigidity, tachycardia, BP changes, hyperthermia, shivering, diarrhoea, altered mental state
Is sertraline licensed for anxiety or not?
No but it is still used
Which SSRI is associated with higher withdrawal effects?
Paroxetine due to shorter half life
What other indications is duloxetine used for?
Urinary incontinence and diabetic neuropathy
Why do we like to use mirtazapine for depression in the elderly?
Fewer antimuscarinic side effects, causes weight gain
What is the main cause of Parkinson’s disease?
Death of dopaminergic cells of the substantia nigra in the brain (reduction of dopamine)
What is the classic presentation for PD?
Rigidity, tremor, bradykinesia, postural instability
What are the two combinations with levodopa?
Co-careldopa (levodopa with carbidopa), co-beneldopa (levodopa with benserazide)
Give some examples of dopamine receptor agonists?
Ergot derived: bromocriptine, cabergoline, pergolide NOT RECOMMENDED.
Non- ergot derived: Pramipexole, ropinirole, rotigotine
Amantadine and apomorphine
Give examples of MAO-B Inhibitors
Selegiline and rasagiline
Give some examples of COMT inhibitors?
Entacapone, tolcapone
What is first line for PD?
(motor symptoms)- levodopa combination only when it affects QOL,
when motor symptoms not affecting QOL: either
a) levodopa combo
b) MAOB inhib
c) non ergot derived dopamine agonists
What if this first line of PD does not work completely?
Add on therapy with either MAOB inhibitor, dopamine receptor agonist (non-ergot derived), or COMT inhibitors
Which antiemetic do you use in PD?
Domperidone
When is the only time ergot derived dopamine receptor agonists are used?
When non ergot derived has not adequately controlled symptoms
What is amantadine useful for?
Dyskinesias- when they’re not adequately managed by current therapy
What is used for PD patients with sleep onset symptoms?
Modafinil – only used for sudden onset of sleep or daytime sleepiness
What is used for PD patients for postural hypotension?
If pharmacotherapy required- midodrine first line, fludrocortisone second line [unlicensed]
What is used for PD patients with psychotic symptoms?
Quetiapine. If not tolerated – clozapine. NB: phenothiazines and butyrophenones can worsen motor features of PD
What is used for PD patients drooling of saliva?
If SALT ineffective, Glycopyrronium bromide first line, botox second line
What is used for PD patients’ dementia?
Acetylcholinesterase inhibitor then memantine hydrochloride
What are the side effects of levodopa?
Impulse control disorders, excessive sleepiness/onset of sleep, motor complications i.e. dyskinesia’s or response fluctuations, end of dose deterioration with shorter length of benefit
What weight is domperidone unlicensed in?
Under 35kg
There are serious cardiac risk factors when using apomorphine and domperidone together (arrhythmia risk due to QT prolongation), what have the MHRA and CHM recommended to reduce this?
An assessment of cardiac risk factors and ECG monitoring to ensure benefits outweigh the risks
Levodopa-carbidopa intestinal gel is administered where?
Directly into the duodenum or upper jejunum (with a portable pump)
When is apomorphine SC intermittent injections or continuous infusion offered?
When a patient has refractory motor fluctuation ‘off’ episodes
What are the side effects of dopamine receptor agonists?
Impulsive control disorders, excessive sleepiness and sudden onset of sleep, psychotic symptoms (i.e., hallucination and delusions), hypotensive reaction in first few days
What class of drug is amantadine?
A weak dopamine receptor agonist
Why can selegiline be considered as a driving offence?
Because it is metabolised to amfetamine
Why can you not have pseudoephedrine and rasagiline together?
They cause hypertensive crisis (same as with any sympathomimetic or any hypertensive drug)
What colour does entacapone colour the urine?
Reddish brown
What is the patient and carer advice for tolcapone?
Recognise signs of liver toxicity- anorexia, nausea, vomiting, abdominal pain, dark urine, pruritis, light stools
What is given to PD patients with rapid eye fluctuations?
Clonazepam or melatonin
Why can we not withdraw dopamine receptor agonists straight away?
Neuroleptic malignant syndrome
What class of drug is ondansetron?
5-HT3 receptor antagonist
What class of patients is ondansetron used in a lot?
Chemotherapy or post-operative patients for nausea and vomiting
What class of drug is domperidone?
Dopamine antagonist
What class of drug is metoclopramide?
Dopamine antagonist
Where does metoclopramide mainly work?
The GI tract- used for emesis in GI, hepatic and biliary disease
When are phenothiazines used in emesis?
diffuse neoplastic disease, radiation and sickness, emesis from opioids, general anaesthetic and cytotoxics
When is dexamethasone used as an antiemetic?
In cancer chemotherapy
What class of drug is Aprepitant?
Neurokinin-1 receptor antagonist
When is Aprepitant and fosaprepitant used/licensed?
N+V associated with emetogenic chemotherapy, and fosaprepitant for HIGHLY emetogenic cisplatin chemo
What class of drug is nabilone?
Synthetic cannabinoid
What is the first line antiemetic in pregnancy?
Drowsy antihistamines like promethazine. Prochlorperazine or metoclopramide are alternatives
Thiamine supplementation is given to patients with hyperemesis gravidarum to prevent what?
Wernicke’s encephalopathy
Age for cyclizine?
> 6
Age for promethazine? (Phenergan)
> 2 (OTC in cough/cold)
Age for cinnarizine?
> 5
Age for prochlorperazine?
> 18 buccastem- max 2 days.
What are the side effects of dopamine antagonist? (typical antipsychotics) in antiemetics
Dystonic reactions, postural hypotension, drowsiness, QT prolongation
What is the MHRA alert for domperidone?
Cardiac side effects- maximum treatment is for 7 days 10mg TDS, over 12y/o and >35kg
What is the MHRA alert for metoclopramide?
EPSE >18- for max only 5 days. Max 500mcg/kg daily (ondan also 5 days)
What antiemetic is also a prokinetic?
Metoclopramide and domperidone
What is used for motion sickness?
A) hyoscine hydrobromide
B) sedating antihistamines
C) antiemetic
Side effects with metoclopramide?
Acute dystonic reactions (especially facial and skeletal muscle spasms)
How do you abort the side effect of metoclopramide?
Procyclidine (it is an anti-parkinsonism drug)
If a drowsy antihistamine is desired for motion sickness, which would be used?
Promethazine, but generally non-sedating ones like cyclizine or cinnarizine is preferred
What is the dosing for cinnarizine for motion sickness OTC? (stugeron)
Take 2 hours before, they last 8 hours
What is the dosing for promethazine for motion sickness OTC? (Phenergan)
Give the night before or 1 hour before and it lasts 24 hours
What is the dosing for hyoscine hydrobromide for motion sickness OTC? (joy rides, travel calm, kwells)
(150mg <3 and 300mg <10) given 30 mins before and lasts 6 hours
What would we use for musculoskeletal pain?
Non-opioids, especially NSAIDs
What would you use for moderate to severe visceral pain?
Opioids
What do you use for neuropathic pain?
TCA’s (amitriptyline/nortriptyline), antiepileptics (gabapentin/pregabalin)
What are the two cautionary and advisory labels on paracetamol?
A) contains paracetamol, do not take anything containing paracetamol whilst ……
B) do not take any more than 2 at any one time, do not take more than 8 in 24 hours
What are the analgesia doses for aspirin?
300-900mg every 4-6 hours as required, maximum 4g a day
What are the two cautionary and advisory labels on aspirin?
Take with or just after food, or a meal AND contains aspirin, do not take anything else containing aspirin whilst taking this medicine
Why is aspirin contraindicated in under 16s?
Reye’s syndrome (exceptions in Kawasaki disease or as an antiplatelet)
What class of CD is dihydrocodeine?
Class 5
What class of CD is tramadol?
Class 3
What class of CD is morphine solution 10mg/5ml?
Class 5 (anything stronger than 13mg/5ml is CD 2
What class of CD is oxycodone?
Class 2
What class of CD is fentanyl?
Class 2
What class of CD is buprenorphine?
Class 3
What class of CD is tapentadol?
Class 2
What fraction of opioid do you give for breakthrough pain?
1/10th to 1/6th of total daily dose of strong opioid every 2-4 hours as required
What is the antidote for opoids?
Naloxone
How do you implement dose increases/increments in morphine patients?
Max dose increment = 1/3 or ½ of total daily dose per 24 hours. NB: equivalent parenteral dose (SC, IV, IM) = half of oral dose
What is the MHRA alert with codeine for children?
Codeine for analgesia: restricted use in children due to reports of morphine toxicity. For acute moderate pain in children OVER 12 only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone. Children aged 12-18= max 240mg daily for 3 days. Dosage = up to four times a day with no less than 6h intervals.
What is the MHRA alert with co-dydramol?
Prescribe and dispense by strength to minimise risk of medication error and risk of accidental overdose
What is the treatment for bone metastases?
Bisphosphonates, radiotherapy, pain management and strontium chloride isotropes
What is the treatment for trigeminal neuralgia?
Carbamazepine
What class of drug is a triptan?
5HT1 receptor agonist
What is the first line for migraines?
Monotherapy with either paracetamol, aspirin, ibuprofen or a 5HT1 receptor agonist if severe (generally 5-HT1 agonist second line)
How long do you have to wait to take a second dose of a triptan?
2 hours
What is first line for migraine prophylaxis?
Propranolol
What is the criteria to get migraine prophylaxis?
Suffer at least two attacks a month, increasing freq of headaches, significant disability despite treatment and cannot take suitable treatment for attacks
What is contained in migraleve?
Codeine, buclizine and paracetamol
Licensing for migraleve?
> 12
Licensing for Imigran
> 18 must be 18-65, clear diagnosis of migraine, not used for prophylaxis, cannot give to cardiac disease etc.
In what child age would you refer insomnia?
Under 12
What are the ages for diphenhydramine?
16 and over
Age for promethazine?
2 and over
How do you take promethazine?
Take 20-30 mins before going to bed, do not use for more than 7-10 consecutive nights
What CD classification is diazepam?
Schedule 4 part 1
What CD classification is diazepam?
Schedule 3
What treatments do we use for narcolepsy?
Modafinil, methylphenidate, dexamphetamine etc
What is acamprosate used for?
Alcohol dependence
How many days do you change the dose of methadone for when a patient has gone without it?
3 or more days (may be less tolerance so dose is decreased) NB if 2 days missed inform rehab but give same dose
How long does it take methadone to reach steady state (Css)?
3-10 days
Which is more sedating out of buprenorphine or methadone?
Methadone
What is suboxone?
An orally active version of buprenorphine and naloxone (prescribed for patients at risk of dose diversion as not orally active but injected would cause a bad reaction)
What do you use for diarrhoea and stomach cramps in heroin withdrawal?
Mebeverine for stomach cramps and loperamide for diarrhoea
List some immediate release formulations for NRT?
Lozenge, gum, inhalator, sublingual tablet, oral spray, nasal spray
How does varenicline work?
Selective nicotine receptor partial agonist, it is a competitive inhibitor of receptors
What is the MHRA alert with varenicline?
Suicidal behaviour, stop and see GP
