CH4: CNS CLINICAL

Question 1

Name the AEDs that have a long half life at ON dosing

Answer 1

LP3

Lamotrigine
Phenytoin
Phenobarbital
Perampanel

Question 2

State the MHRA warnings for AEDs

Answer 2

1. Risk of suicidal thoughts & behaviours
2. Risk of teratogenicity in 1st trimester (1-12 weeks)
3. Risk of respiratory depression with use of gabapentin and pregabalin

Question 3

State the 1st line treatment for focal seizure?

Answer 3

2Ls

Lamotrigine
Levetiracetam

Question 4

State the 2nd line treatment options for focal seizures

Answer 4

COZ

Carbamazepine
Oxycarbamazepine
Zonisamide

Question 5

State the 1st and 2nd line treatment of Tonic-clonic seizures

Answer 5

SALL

1st line: Sodium Valproate
2nd line: Lamotrigine/Levetiracetam

Question 6

State the 1st, 2nd and 3rd line treatment of absence seizures

Answer 6

ESALL

1st line: Ethosuximide
2nd line: Sodium Valproate
3rd line: Lamotrigine/levetiracetam

Question 7

State the 1st and 2nd line treatment of myoclonic seizures

Answer 7

SALE

1st line: Sodium Valproate
2nd line: Levetiracetam

Question 8

State the 1st and 2nd line treatment and add- on-therapy of Atonic seizure

Answer 8

SLARCT

1st line: Sodium Valproate
2nd: Lamotrigine

Add-on therapies
Rufinamide
Clobazam
Topiramate

Question 9

State the 1st and 2nd line treatment and add- on-therapy of Tonic seizure

Answer 9

SLARCT

1st line: Sodium Valproate
2nd: Lamotrigine

Add-on therapies
Rufinamide
Clobazam
Topiramate

Question 10

Acute treatment for anxiety

Answer 10

low dose of benzodiazepines, short duration

Question 11

Chronic treatment for anxiety

Answer 11

SSRIs (sertraline, fluoxetine, citalopram, escitalopram)
Propranolol = to alleviate physical symptoms (BP, HR)

Question 12

What type of benzodiazepines are preferred in elderly pts?

Answer 12

short acting benzodiazepines: lorazepam & oxazepam

Question 13

What type of benzodiazepines are preferred in pts with hepatic impairment?

Answer 13

short acting benzodiazepines: lorazepam & oxazepam

Question 14

What are the risks of short-acting benzodiazepines?

Answer 14

Greater risk of withdrawal symptoms
Advise to use for 2-4 weeks

Question 15

Prescribing pathway for mild depression

Answer 15

CBT

Question 16

Prescribing pathway for moderate to severe depression

Answer 16

1st line - SSRIs (better tolerated and safe in OD), SERTRALINE

Question 17

How long does it taken for antidepressants to work

Answer 17

usually 4 weeks, 6 weeks for elderly
this is the duration we would consider before deeming ineffectiveness of a drug

Question 18

After remission from depression, how long should we consider continuing antidepressants usually?

Answer 18

6 months after remission

Question 19

After remission from depression, how long should we consider continuing antidepressants for an elderly patient?

Answer 19

1 year after remission

Question 20

After remission from depression, how long should we consider continuing antidepressants if a patient has recurrent remission?

Answer 20

2 years

Question 21

State the treatment pathway for depression

Answer 21

1st line - SSRIs (usually sertraline)
if not effective – increase dose, change SSRI (2nd line is Mirtazapine)
in rare cases, MAO-Is (specialist initiation)
severe cases, TCA or venlafaxine (SNRIs)

if still ineffective
- add another class, lithium or antipsychotics
- use ECT for severe refractory depression

Question 22

Name the effects caused with Serotonin syndrome (SS)

Answer 22

1. Cognitive effects - headache, hypomania, coma, agitation, confusion
2. Autonomic effects - nausea, diarrhoea, sweating, hyperthermia
3. Neurotransmitter excitation - tremor, teeth grinding

Question 23

Name the drugs that cause Serotonin syndrome

Answer 23

1. SSRIs
2. TCAs
3. MAO-Is
4. Triptans
5. Lithium
6. Tramadol

Question 24

A 56-year-old man, who is an inpatient, has a 2-minute generalised tonic–clonic seizure. He was admitted 1 week ago with chest pain caused by a pulmonary embolus. Dalteparin, warfarin, paracetamol and ibuprofen had been started. Three days ago, he was found to have hospital-acquired pneumonia, and meropenem was added. He has a past medical history of epilepsy. He takes sodium valproate (Epilim Chrono®) 500 mg 12-hrly. He is allergic to penicillin (it brings him out in hives).
What medication is most likely to have interacted with valproate to increase the risk of seizures?

A. Dalteparin

B. Ibuprofen

C. Meropenem

D. Paracetamol

E. Warfarin

Answer 24

Answer: C

Meropenem.
Drug interactions are a common problem with many antiepileptic agents, including valproate, carbamazepine, lamotrigine and phenytoin. Valproate has a particularly serious interaction with carbapenem antibiotics, characterised by a rapid (within days) and profound (near-complete) reduction in serum valproate concentrations. This may lead to a loss of seizure control. Concurrent administration should be avoided if possible. If treatment with a carbapenem is essential in a patient taking valproate, the serum valproate concentration should be monitored closely. The mechanism of the interaction is unclear.