Chapter 4: Nervous system Flashcards
In what situations would you consider migraine prophylaxis?
- suffer at least two attacks a month;- suffer an increasing frequency of headaches;- suffer significant disability despite suitable treatment for migraine attacks;- cannot take suitable treatment for migraine attacks
What are the most effective drug treatments for smoking cessation?
VareniclineorCombination of long acting NRT (patch) AND short acting NRT (gum, lozenge etc)
What are the symptoms of carbamazepine toxicity (I HANDBAG)?
In co-cordinationHyponatraemiaAtaxiaNystagmusDrowsinessBlurred vision, diplopiaArrhythmiasGI disturbances
Are SSRIs or TCAs more sedating?
TCAs are more sedating also have more antimuscarinic and cardiotoxic side effects
Which antipsychotics commonly cause weight gain?
ClozapineOlanzipine
The ability to metabolise codeine into morphine can vary greatly between individuals. Ultra rapid metabolisers are more susceptible to toxicity. What enzyme is involved?
CYP2D6
What withdrawal period is required for fluoxetine what about other SSRIs
5 weeks Other SSRIs: Up to 2 weeks
What patient advice is needed for galantamine?
Risk of serious skin reaction including Stevens-JohnsonStop taking if reaction occurs
Can antipsychotics interfere with your temperature regulation?
Haloperidol and risperidone
Are first or second generation antipsychotics more likely to cause insulin resistance and diabetes?
Second generation is more likely
What is the problem with enteric coated aspirin in acute pain?
Slow onset of action
At what body weight should IV paracetamol be adjusted and what dose should you use?
<50kg15mg/kg
What are the main side effects to look out for if a patient is on carbamazepine?
Blood or skin disorders Antiepileptic hypersensitivity syndromeSeek medical help if fever, rash, mouth ulcers etc occurALSO can cause hepatotoxicity so report signs of dark urine, nausea, vomiting
CD schedule is Morphine sulphate solution 2mg/ml?
CD Schedule 5 Inv POM It is only when the level of morphine exceeds 13mg/ 5ml (2.6mg/ml) that the solution becomes CD Schedule 2
What is first line treatment options for patients with mild to moderate Alzheimer’s?
Monotherapy with one of the following Ach inhibitors: Donepezil Rivastigmine Galantamine Drug treatment should only be initiated under a specialist (however can then be managed in primary care)
Can Fentanyl be used in opioid naive patients
NO Manufacturer advises use only in opioid tolerant patients due to risk of respiratory depression
What monitoring is required at the start of antipsychotic treatment?
Full blood count, urea and electrolytes, and liver function test monitoringBlood lipidsWeight Fasting blood glucose and blood pressureECG if history of cardiovascular risk factors present
Which antipsychotic is least likely to cause hyperprolactinaemia?
Ariprazole
What is the max daily dose of sumatriptan bought OTC dose previously diagnosed migraine?
comes as 50mg tabs OTC: Max 2 daily (100mg)
What is 1st line for newly diagnosed focal seizures?
Carbamazepine or Lamotrigine
What is first line for patients with severe Alzheimer’s in someone who is not on any medication for the condition?
Memantine
What are specific side effects of IV phenytoin?
Bradycardia Hypotension
What can cause sensations of tingling, heat, pressure, tightness in the body?
Triptans! Discontinue if intense
How would you treat trigeminal neuralgia (facial pain with electric shocks in the jaw)?
True but symptoms must have been improved after taking the first tablet
What is the advice surrounding antipsychotics and sunlight?
As photosensitisation may occur with higher dosages, patients should avoid direct sunlight.
What is the recommendation of opioid withdrawal in pregnancy during:i) 1st trimesterii) 2nd trimesteriii) 3rd trimester
1st trimester- avoid as increased risk of spontaneous miscarriage2nd trimester - can do withdrawal however needs to be slow (dose reduction every 3-5 days) 3rd trimester - avoid as increased risk of stillbirth and foetal distress
In schizophrenia, are antipsychotics more effective on the negative or positive symptoms?
More effective on the positive symptoms
Which TCA is frequently associated with hepatotoxicity?
Lofepramine
What can we use to treat cluster headache?
Sumatriptan (given by SC injection) or Zolmitriptan
How would you reduce someone’s diazepam dose if on long term therapy to prevent withdrawal?If on high doses, how is this done?
Within 3 weeks
Does lamotrigine need to be prescribed by brand?
Based on clinical judgement - Category 2
Ganglionic blockers’ main agent?
ABCDsA - agitationB - blurred visionC - constipation/ confusionD - dry mouthS - stasis of urine and sweating
When should NRT be used in smoking pregnant patients?
Only if non-drug treatment options have failed
What are the side effects of ergot derived dopamine agonists?
Non ergot derived dopamine agonist
Pregnant patients who are taking what antiepileptics should have fetal growth monitoring?
Topiramate or levetiracetam
What is the risk of abrupt lithium withdrawal?How should it be withdrawn?
Increases the risk of relapse The dose should be reduced gradually over a period of at least 4 weeks (preferably over a period of up to 3 months).
What would be an appropriate benzodiazepine for someone suffering from insomnia with daytime anxiety?
Short acting
Which antipsychotics may need their dose adjusting according to smoking status during therapy?
Clozapine, Haloperidol, Chlorpromazine and Olanzapine
What vitamin supplementation should you consider if a patient is on carbamazepine?
Vitamin D - Especially if immobilised for long periods, or who have inadequate sun exposure/dietary intake of calcium
Mrs M has epilepsy but she is not any medication for it at the moment as she hasn’t had a seizure for two years and is now pregnant. Does she need to sign up to the Epilepsy Register?
Yes, whether on medication or not, she still needs to
Which antipsychotic can cause contact sensitisation so should be handled with care?
Chlorpromazine tablets should NOT BE CRUSHED
What is the difference between Shortec and Longtec
Shortec- immediate release oxycodoneLongtec- modified release oxycodone
Can methadone cause QT prolongation?
3 weeks maxIdeally 1 week
Has pregabalin got an MHRA warning on the risk of severe respiratory depression?
4-12 mg/L
What class of drug is dosulepin?
TCA
True or false:A benzodiazepine may be used as short-term adjunctive therapy at the start of antidepressant treatment to prevent the initial worsening of symptoms.
Can help with the autonomic physical symptoms e.g. tremor and palpitationsThey do not reduce non-autonomic symptoms, such as muscle tensionThey do not help with psychological symptoms
Examples of antimuscarinic drugs
Day 1 - 300mg ODDay 2 - 300mg BDDay 3 -300mg TDS
True or false:You can take two doses of sumatriptan for the same attack 2 hours later?
Yes
How long after discontinuation of MAOIs can interactions still occur
Up to 2 weeks. That’s why a withdrawal period is required. Moclobemide is short acting so does not require a withdrawal/washout period
Which analgesics have been associated with psychiatric reactions/ hallucinations?
Tramadol Pentazocine (avoid this after a myocardial infarction)
Is haloperidol a first or second generation antipsychotic?
First
Can lithium be used in pregnancy?
Teratogenic including cardiac abnormalities - avoid if possible Especially in 1st trimester In 2nd and 3rd trimester: dose may need to be increased but on delivery return abruptly to normal
phenothiazine are a class of antipsychotic agents that are used for the antiemetic treatment of nausea and vertigo and also migraines. Can you name any drugs in this class?
Piperazines, Prochlorpromazine, Fluphenazine, Trifluoperazine, chlorpromazine, promazine, triflupromazine
What are SSRIs cautioned in?
Cardiac diseaseBleeding- especially GI Epilepsy as they can cause seizures
Withdrawal symptoms can occur without how much time of stopping a short acting benzodiazepine?
Carries greater risk of withdrawal symptoms
Are e-cigs licensed is smoking cessation?
No - aways recommend a licensed treatment if asked e.g. NRT patch
Scopolamine
1 antimuscarinics2 Ganglionic blockers3 Neuromuscular blockers
Which of these side effects is not associated with lithium?HyperthyroidismTremorsIncreased urination/thirstLeukocytosis
HyperthyroidismAssociated with hypothyroidism
Which drug, used in parkinsons, should you avoid taking iron-containing products at the same time of day??
Entacapone, as it may form CHELATES WITH IRON, affecting its absorption
What is the interaction between TCAs and antihypertensives?
Yes
Levodopa is associated with what side effect?
Motor complications, including response fluctuations (on and off periods) and dyskinesiasTake at specific times of the day to avoid “off” periods However, the overall motor improvement is more noticeable with levodopa
What do patients and carers need to look out for in those taking carbamazepine and phenytoin?
Signs of blood, hepatic or skin disorders: Fever Rash Ulcers Bruising and bleeding - Known as Leucopenia (low white cell count, but this is NOT the same as agranulocytosis)
In what situations is it advised for patients to immediately remove a fentanyl patch?
TRUE
What is the risk of long term benziodiazepine therapy in the management of insomnia?
Rarely benefited by hypnotics and is sometimes due to mild dependence caused by injudicious prescribing of hypnoticsThe underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia.Anxiety, depression, and abuse of drugs and alcohol are common causes
True or false:Pethidine has multiple strengths in tablet form
False- only has 50mg strength so do not legally need to state the strength on the prescription
If a patient fails to respond to their first line SSRI treatment for depression, what would be the options?
Increasing the doseSwitching to a different SSRI or mirtazapineOther 2nd line options:Lofepramine (TCA), moclobemide (reversible MAOI), and reboxetine (NRI)
Antidepressants can cause hyponatreamia. What are the symptoms of this?
Confusion, Drowsiness, Convulsions
True or false: For migraine relief, if a patient does not respond to one 5HT1-receptor agonist, an alternative 5HT1-receptor agonist should be tried.
TRUE
What is the important safety information regarding bromocriptine and cabergoline?
Associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions.Impulse control disorders
What is an important side effect to look out for with ethosuximide?
Blood disorders (fever, mouth ulcers, or bleeding develops)
Which anti-epileptic is particularly associated with hepatic dysfunction and what are the symptoms?
Sodium valproate - Persistent vomiting, abdominal pain Anorexia, jaundice, oedema, malaise Monitor liver function before therapy and during first 6 months of treatment! - always check alcohol usage in patients as this increases the risk further
Madopar contains which drug?
Co-beneldopa
What schedule is tramadol?
Schedule 3 CD No Reg Exempt from safe custody Prescription requirements and 28 day validity still stand
What parkinsons disease drug colours your urine reddish brown?
Entacapone
What are the two different Lithium salts?
Lithium Carbonate: Camcolit, Priadel, Liskonium tablets Lithium Citrate: Li-liquid, Priadel liquid (citrate only comes as a liquid) Rx by brand
Name some medication used in ADHD?
CNS Stimulants: - Methylphenidate (Ritalin (IR), Concerta (SR), Medikinet, Equasym) - Dexamfetamine Lisdexamfetamine (prodrug of dexamfetamine, Elvanse, Elvanse Adult) Atomoxetine Clonidine (specialist)
Anticholinergic adverse effects
Trihexyphenidyl exerts its effects by reducing the effects of the relative central cholinergic excess that occurs as a result of dopamine deficiency.
What is antiepileptic hypersensitivity syndrome?
Rare but potentially fatal syndrome associated with some antiepileptic drugsThe symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy (enlarged lymph nodes) are most commonly seen.
What antidepressant can be used for smoking cessation?
Bupropion
What type of drug is venlafaxine?
SNRI
What do you need to consider in the third trimester in terms of methadone and drug metabolism?
Drug metabolism can be increased in the third trimester; it may be necessary to either increase the dose of methadone hydrochloride or change to twice-daily consumption (or a combination of both strategies) to prevent withdrawal symptoms from developing.
What drug should be used to manage febrile convulsions?
Brief febrile convulsions (resulting from high temp/ fever) require no specific treatment, just anti-pyretic medication- paracetamol!!
What is the antisickness choice of drug in Parkinson’s?
Hepatotoxicty Look out for vomiting, dark urine, abdominal pain
What would be the starting dose of amitriptyline for neuropathic pain?
Major depressive disorder- not recommendedMigraine prophyaxisNeuropathic pain
Smokers who wish to stop smoking should be referred to where?
Their local NHS Stop smoking services
Can mirtazapine cause QT prolongation?
Yes
What antidepressant is the safest in those with parkinsons?
Quetiapine
Which anti-epileptic is cautioned in patients with a LOW BODY WEIGHT?
Zonisamide - Monitor weight throughout treatment as fatal cases of weight loss reported in children.
Which antieplieptic could be a problem in patients with glaucoma?
Topiramate Associated with acute myopia (short sightedness with secondary angle closure glaucoma SE: kidney stones
Are antipsychotics better at treating positive or negative symptoms?
Positive
Which SSRIs have the greatest risk of withdrawal syndrome
Paroxetine and Venlafaxine (SNRI) due to their shorter half lives dose to be decreased gradually over at least 4 weeks
After how many weeks is anxiety classed as chronic?
4 weeks
Is long term anticonvulsant prophylaxis recommended?
Rarely indicated
Taking trimethoprim with phenytoin primarily increases the risk of what?HyperkalaemiaMegaloblastic anaemiaBleedingLow sodium
Megaloblastic anaemiaTrimethoprim inhibits folate synthesisPhenytoin increases folate metabolism(Same with trimethoprim and methotrexate)
How long should a patient not drive through after a seizure in established epilepsy?How about if the seizure was whilst the patient was asleep?
6 months
What is the patient advice regarding disulfiram?
Should be counselled on the disulfiram-alcohol reaction—reactions may occur following exposure to small amounts of alcohol found in perfume, aerosol sprays, or low alcohol and “non-alcohol” beers and wines; symptoms may be severe and life-threatening and can include nausea, flushing, palpitations, arrhythmias, hypotension, respiratory depression, and coma.Patients and their carers should be counselled on the signs of hepatotoxicity—patients should discontinue treatment and seek immediate medical attention if they feel unwell or symptoms such as fever or jaundice develop.
What antiepileptic is licensed for migraine prophylaxis?
Topiramate
Can varenicline be used alongside bupropion for smoking cessation?
No
Why aren’t fentanyl transdermal patches suitable for patients requiring rapid titration of dose/ changing doses all the time?
Due to the long time to steady state (24-72 hours)
At what strength does Oramorph solution turn from a Schedule 5 CD to a schedule 2?
Strengths exceeding 13mg/ 5ml
What is the max dose of pregabalin a day?
Peripheral AND central neuropathic pain
Should we routinely monitor plasma valproate levels?
No Not a useful index of efficacy - Should monitor liver function, before and first 6 months Also measure FBC as blood disorders noted with valproate and check if patient is of child-bearing age
Sinemet contains which drug?
Co-careldopa
What is the difference between haloperidol and haloperidol decanoate? Same with zuclopenthixol and zuclopentixol decanoate?
Decanoate is used for maintenance in schizophrenia only Should NOT be used for short term management of an acute episode e.g. zuclopentixol acetate used for this (rapid tranq.)
What is gabapentin used for in terms of pain?
3.6g
Why are opioids cautioned in respiratory disease such as COPD and acute attacks of asthma
This is because of their potential to produce respiratory depression
What is the MHRA advice surrounding switching between different manufacturers’ products in epilepsy?
Antiepileptic drugs have been divided into three risk-based categories to help healthcare professionals decide whether it is necessary to maintain continuity of supply of a specific manufacturer’s product. Category 1:Carbamazepine, phenobarbital, phenytoin, primidone. For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product. Category 2:Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide. For these drugs, the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with the patient and/or carer taking into account factors such as seizure control Category 3:Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin. For these drugs, it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed
Which antiepileptic do we need to be careful with in liver impairment?
Sodium valproate Monitor LFTs
Atonic and clonic seizures are usually seen in which patient group?What is the drug of choice for this?
Childhood or associated with cerebral damage or mental retardation - Sodium valproate Lamotrigine can be added
With what MAOIs are hepatotoxicty more likely?
Reversible - no washout period needed as it is short acting
Which anti epileptic should patients be warned to look out for signs of fever, rash, mouth ulcers, bruising, bleeding?
Carbamazepine Signs of blood, hepatic or skin disorders do not use for absence or myoclonic seizures
If a patient is on an antidepressant and is going to be changed to an MAOI, what time period should they have stopped the previous antidepressant?
2 weeks 3 weeks if starting clomipramine or imipramine
Why are benzodiazepines cautioned in hepatic impairment?If they are needed, are short or long acting ones recommended?
Can precipitate comaShort acting(However, in alcohol withdrawal, a long acting e.g. chordiazepoxide or diazepam is used via fixed dosed regimen)
Which antimuscarinic, used for drug-induced parkinsons, should be taken with or after food?
Trihexyphenidyl hydrochloride
Surely CNS stimulants Indicated for ADHD would make it worse?
Stimulants increase dopamine and norepinephrine in the brain, and increase blood flow to the brain. This stimulates the child… A child with ADHD has something called “self-stimulation” where they are constantly stimulated and never switch off. Giving drugs that cause stimulation kind of distracts them from this self-stimulation, so it actually calms them down and they just have a normal level of stimulation, as soon as their mind focuses on something else their self-stimulation goes away
Capsaicin cream 0.075% is licensed in what?
Post herpetic neuralgiaPainful diabetic neuropathyOsteoarthritis
A patient on warfarin requests a pack of aspirin 300mg OTC to treat a headache. What do you do?
Increased risk of bleeds when aspiring given with coumarins due to its anti-platelet effect.
What should patients on Bromocriptine for parkinsons be advised with regards to OTC drugs?
Important to warn patients not to take OTC sympathomimetics when taking bromocriptine, such as pseudoephedrine, as this could lead to severe peripheral vasoconstriction, ventricular tachycardia and seizures and therefore may be fatal.
If it does need diluting, IV phenytoin should be administered in what fluid via what and why?
Sodium chloride Via large vein, in line phenytoin filter is needed as it precipitates easily
Which parkinsons medication may cause hair loss (alopecia) and hypersexuality as a side effect?
Selegiline (MAO-Bi) - Also gets converted to amphetamines so DRUGS AND DRIVING
What is the MHRA warning regarding prescribing antipsychotics in elderly patients with dementia?
Increased risk of stroke and a small increased risk of death If needed, use the lowest effective dose and for the shortest time Review every 6 weeks
What is the target plasma concentration of the TDM drug phenytoin?
10-20mg/L
What antiepileptics can cause blood dyscrasias?
CarbamazepineValproateEthosuximideTopiramatePhenytoinLamotrigineZonisamide
What is the NICE 2017 guidance surrounding choice of Donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease?
The three acetylcholinesterase (AChE) inhibitors donepezil, galantamine, and rivastigmine as monotherapies are recommended as options for managing mild to moderate Alzheimer’s diseaseIf prescribing an AChE inhibitor (donepezil, galantamine, or rivastigmine), treatment should normally be started with the drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, an alternative AChE inhibitor could be prescribed if it is considered appropriate
What is nystagmus?
Involuntary eye movement
Sexual dysfunction is most common with what antipsychotics?
If 2 or more doses missed, then need to re-titrate dose
Is withdrawal more common with short or long acting benzodiazepines?
Can cause rebound insomnia and a withdrawal syndrome.
What are the contraindications for benzodiazepines?
Acute pulmonary insufficiency; marked neuromuscular respiratory weakness; sleep apnoea syndrome; unstable myasthenia gravis
In what patients are Dexamfetamine and Lisdexamfetamine cautioned
Tics & Tourettes History of epilepsy Mild hypertension Susceptibility to angle closure glaucoma May also cause growth restriction in children
what is the interaction with tramadol and alcohol
Alcohol can increase the nervous system side effects of tramadol such as dizziness, drowsiness, and difficulty concentrating.
Which benzodiazepines can be used in epilepsy management (not status epilepticus)?
ClobazamClonazepam
Short acting benzodiazepines?
Midazolam - Used for epileptic seizures (SE) and febrile convulsions due to its fast onset
Which drug used to aid smoking cessation should be discontinued if the person becomes agitated, depressed or suicidal?
Varenicline This is a selective nicotine receptor partial agonist
What are the weak opioids?
CodeineDihydrocodeineMeptazinol
True or false:Routine injection of vitamin K at birth minimises the risk of neonatal haemorrhage associated with antiepileptics.
TRUE
What class of drug is ropinerole?
Non ergot derived dopamine agonist
What antiemetic is associated with an increased risk of neurological effects, such as tardive dyskinesia and EPSEs?
Metoclopramide: particularly in young adults (females aged 15-19) Should not be routinely given to patients under 18 years old Only for short term use (up to 5 days) Drug of choice for nausea associated with myocardial infarction. Can also be used in chemo/radio/postop induced n/v + hiccups,n/v in pall care Avoid use in Parkinson’s + Epilepsy When used for migraine: treatment should not exceed 3 months due to risk of tardive dyskinesia
Hyponatreamia has been linked to all antidepressants, but is more likely with which class?
SSRIs
What would be first line in the following condition:A patient with Parkinson’s whose motor symptoms are NOT affecting their quality of life
Could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).
Why is it important to stick to the same brand of lithium?
Not all brands are bioequivalent. Brands are typically within 5% (95%-105%) Changing the preparation would require the same precautions and monitoring as initiating treatment for the first time
If a patient is on an opioid withdrawal regime but starts to use illicit drugs again, what should happen?
The withdrawal regimen should be stopped and maintenance therapy should be resumed at the optimal dose.
What type of drug is duloxetine?
SNRI
What are the irreversible and reversible MOAI
Phenelzine, Isocarboxazid, Tranylcypromine (irreversible inhibition) Moclobemide (reversible inhibition)
What are the signs of benzodiazepine withdrawal?
2-4 weeks
what are the intermediate acting benzodiazepines
Clonazepam Lorazepam Oxazepam Temazepam CLOT (Hence why some of these are used for agitation in our patients: As long-acting ones increase drowsiness)
What are the less sedating TCAs?
Imipramine hydrochloride, lofepramine, and nortriptyline.
Bromocriptine, Cabergoline, and Pergolide are all stimulants of dopamine receptors in the brain, used in Parkinson’s. What are some specific safety warnings associated with these?
Impulse control disorders - gambling, shopping Sudden onset of sleepiness: avoid driving Hypotensive reactions during first few days of treatment
Can SSRIs cause QT prolongation?
Yes
Stalevo contains which drug combination?
Levodopa, carbidopa, entacapone
Trihexyphenydil
TolterodineSolifenacinOxybutyninFesoterodine M3 receptor. overall efficacy similar.
What risk does Topiramate carry in terms of harm to foetus?
Risk of Cleft palate (cleft lip) Topira - palate
What are the symptoms of TCA overdose?
HypotensionHypothermiaConvulsionsRespiratory failureDilated pupilsUrinary retention
What criteria must an epileptic meet if they want to drive their car?
-Seizure free for 1 year (those that have had their first seizure must not drive for 6 months after the event) -If they only have seizures in their sleep: 3 year past of sleep attacks with no awake attacks -No recent medication changes or withdrawal: if so 6 months must have elapsed
How do you manage status epilepticus?
- IV lorazepam if seizure has lasted more than 5 minutes - Must have resuscitation facilities available (if not, use rectal diazepam or buccal midazolam although absorption is slower) - Can administer lorazepam again after 10 mins if no response- If after 25 minutes after onset and no response, give phenytoin (slow IV)/fosphenytoin (can be given more rapidly) /phenobarbital- If after 45 minutes after onset and no response, sedate patient
What is the desired total serum concentration for phenytoin?What can be a disadvantage of measuring total concentration?
10-20mg/LHowever, need to be careful as there are certain conditions where protein binding may be reduced e.g. elderly There is also reduced protein binding in the first 3 months of life It may be more appropriate to measure free plasma phenytoin concentration
What is the advice regarding treatment cessation of antipsychotic drugs?
There is a high risk of relapse if medication is stopped after 1–2 years. Withdrawal of antipsychotic drugs after long-term therapy should always be gradual and closely monitored to avoid the risk of acute withdrawal syndromes or rapid relapse. Patients should be monitored for 2 years after withdrawal of antipsychotic medication for signs and symptoms of relapse.
What is a disadvantage of short acting benzodiazepines?
ElderlyHepatic impairment (however in acute alcoholic withdrawal a longer benzodiazepine is used)
Can TCAs cause QT prolongation?
Yes
How long are nicotine patches generally applied for?In what group of patients would this be longer?
16 hours a day, patch removed overnight24 hours a day is the patient experiences strong nicotine cravings upon waking
What are the signs of phenytoin toxicity?
Nystagmus (uncontrolled eye movement) Diplopia (double vision) Slurred speech Ataxia (uncontrolled body movement) Confusion HYPERglyceamia No Dude Seizures Are Crazy Hhigh
Selegiline is what type of drug?
Monoamine oxidase B inhibitor
Withdrawal symptoms can occur without how much time of stopping a long acting benzodiazepine?
Within 1 day
Are typical antipsychotics first or second generation antipsychotics?
First generation
What is the ideal level range for lithium?For acute episodes of mania, what would the target level range be?
0.4–1 mmol/litre -lower end for elderly and for maintenance therapy 0.8–1 mmol/litre is recommended for acute episodes of mania
What is methylphenidate used for?
ADHD
Can antipsychotics cause neuroleptic malignant syndrome?
Yes
What is the max strength of codeine that you can buy OTC?
12.8mg Present in Solpadeine Max and Panadol Ultra
What is the advice surrounding clozapine and missed doses?
Phenelzine Isocarboxazid
What is the MHRA warning regarding codeine?
Restricted use in children due to reports of morphine toxicityCodeine should only be used to relieve acute moderate pain in children older than 12 years and only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone. A significant risk of serious and life-threatening adverse reactions has been identified in children with obstructive sleep apnoea who received codeine after tonsillectomy or adenoidectomy
Prochlorperazine belongs to the phenothiazine class of antipsychotic agents that are used for the antiemetic treatment of nausea and vertigo. What is their M of A?
Act centrally by blocking the chemoreceptor trigger zone
Which antiemetic is associated with a small increased risk of cardiac effects?
Domperidone QTc prolongation Treatment should not exceed 1 week Do not use in <12 years/<35kg as no evidence of effectiveness
What is lofexidine used for?
Management of symptoms of opioid withdrawalCan be prescribed as an adjuvant to opioid substitution therapy
Long term use of opioids can result in
Hypogonadism (sexual dysfunction) Adrenal insufficiency Hyperalgesia: abnormal pain sensitivity (develop tolerance)
Why should codeine be avoided in breast feeding mothers?
Mothers vary in their capacity to metabolise codeine to morphine, risk of morphine overdose in the infant. This does not apply to dihydrocodeine
What would be first line in the following condition:A patient with Parkinson’s whose motor symptoms are decreasing their quality of life
Co-carelopda or co-benelopda
Which anti-emetic is of value in the treatment of nausea and vomiting associated with cytotoxic use in cancers?
Ondansetron
Early treatment with____ can delay the need for levodopa therapy in Parkinsons
Selegiline
What antiepileptics have an established risk of drowsiness in babies?
BenzodiazepinesPhenobarbital Primidone
Which TCA should be initiated by a specialist?
Dosulepin
Where should you apply an NRT patch?Do you have to rotate sites of application?
Trunk, upper arm, hipYes- Avoid using the same site for several days
What are the main side effects of antipsychotics?
NAME?
How many weeks is a course of varenicline?
12 weeks
Which CNS stimulant is licensed for use in Narcolepsy?
DexamfetamineCan also use methylphenidate but this is unlicensed use
What is the patient advice surrounding MAOIs?
Advised to only eat fresh foods and avoid “going off” or stale food (meat, fish) Avoid alcohol Avoid large amounts of tyramine-rich foods e.g. mature cheese - hypertensive reaction
What are the side effects of opioid analgesics?
NAME?
What would be the dosing regimen of gabapentin in neuropathic pain?
Only peripheral neuropathic pain
What is ergotamine used for?In what patient groups would this not be appropriate for?
Cluster headaches - unlincensedcoronary heart disease; hyperthyroidism; inadequately controlled hypertension; obliterative vascular disease; peripheral vascular disease; Raynaud’s syndrome; sepsis; severe hypertension; temporal arteritis
What is a potential side effect of IV fentanyl?
Muscle rigidity (may involve thoracic muscles)
What is the important safety information associated with dopamine-receptor antagonists e.g. levodopa?
Impulse control disorders e.g. gambling, binge eating
How does lithium interact with amiodarone?
Risk of ventricular arrhythmias
In patients with moderate Alzheimer’s, what is the risk of stopping Ach inhibitor treatment?
Can cause a substantial worsening in cognitive function
Is clozapine a first or second generation antipsychotic?
Second
What is the patient advice regarding co-benelodopa?
Sudden onset of sleep Caution when driving/operating machinery
How does phenytoin interact with NSAIDs?
Effect of phenytoin enhanced by NSAIDs
For short term insomnia, hypnotics should not be used for longer than what?
Short acting
Codeine Max dose- adults
240mg per day (8 tablets- same as paracetamol)
What neurological condition is amantadine used in?
Parkinson’s Disease
How do TCA’s work?
Block the reuptake of both noradrenaline and serotonin, although each to different extents.
What antiepileptics accumulate in breast feeding children due to a slower metabolism?
Phenobarbital Lamotrigine
Is lorazepam short or long acting?
Short acting - little or no hangover effect