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
What class of drug is pramipexole?
Lower dose needed for therapeutic effectFewer side effects - nausea, vomiting, cardiovascular events
Coarsened facial appearance, acne, weight loss, constipation, dizziness, mouth tenderness, headache, nausea All side effects of?
Phenytoin
What is the risk of prescribing antipsychotics in patients with Lewy body/Parkinson’s Disease dementia?
Antipsychotic drugs can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions
What is the difference between oxynorm and oxycontin?
Oxynorm- immediate release oxycodoneOxycontin- modified release oxycodone
What conditions are stimulants (methylphenidate, lisdexamfetamine, atomoxetine etc) used in ADHD cautioned in?
Heart conditions This is because they can cause tachycardia (fast heart beat)
What is a risk with IV diazepam?
Venous thrombophlebitis
What has IV infusion of Fosphenytoin been associated with?
Severe cardiovascular reactions
When should SSRI’s be taken? What about TCA’s? What about Mirtazepine?
SSRI’s- take in the morning as they are mildly stimulating TCA’s- take at night as can cause drowsiness Mirtazepine (tetracyclic)- take at night as can cause drowsiness
How often should serum lithium monitoring take place in the initial and continuous treatment phase?
Weekly initially Weekly after every dose change 3 months thereafter
What Acetylcholinerase inhibitor is licensed for dementia in Parkinson’s Disease (Lewy body)?
Rivastigmine
What is 1st line for mild depression if a patient is presenting for the first time?
TRUE
Signs of lithium toxicity?
Within therapeutic range: Nausea, vomiting, diarrhoea, weight gain, dehydration - polyuria, hypernatraemia Severe: Hand tremor, irritability, slurred speech, stupor (numbness), nephrotoxicity, arrhythmias, coma, seizures (H I S, S N A C S)
What can you use for prophylaxis of bipolar disorder?
BenzodiazepinesAntipsychotics- quetiapine, olanzapine, risperidone Lithium or valproic acid can be added if inadequate response
What is used as adjunct to co-beneldopa or co-careldopa to reduce ‘end of dose’ deterioration?
Selegiline - can be used alone Enatcapone Tolcapone
For chronic anxiety, what is used?
Antidepressant - SSRI If patient cannot tolerate SSRI, pregabalin can be considered Benzodiazepine may be needed until the antidepressant starts to work
What are the symptoms of serotonin syndrome?
Neuromuscular hyperactivity (such as tremor, hyperreflexia, clonus, myoclonus, rigidity), autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea), and altered mental state (agitation, confusion, mania).
How does lithium interact with loop and thiazide diuretics?
Excretion of lithium reduced by Loop and Thiazide – Sodium depletion
For smoking cessation, how much treatment should be prescribed for the patient?
2 weeks with an assessment just before their supply finishes
For patients on opioid maintenance therapy, what should happen if they miss:1) 3 or more days 2) 5 or more days
1) In community pharmacy, refer back to the prescriber. They should consider reducing the dose2) An assessment of illicit drug use is also recommended before restarting substitution therapy
Why is phenytoin cautioned in hepatic impairment?
Decreased protein binding so increased risk of toxicity
What types of toxicity is associated with sodium valproate?
Blood disorders Hepatic failure Pancreatitis
Does levetiracetam need to be prescribed by brand?
No - Category 3
What is the therapeutic range for carbamazepine?
QT prolongation
True or false:Phenytoin inhibits Vitamin D metabolism
FalseIt induces Vitamin D metabolism- consider supplementation in immobilised patients/inadequate sun exposure or dietary intake of calcium
When should lithium be taken?
At night- blood test needs to be 12 hours post-dose and blood test usually in the morning
Which antidepressant is safest to use in a patient with unstable angina/ had a recent Myocardial Infarction?
Sertraline (SSRI)
When should antidepressants be avoided in bipolar?
In MANIC phase Rapid cycling bipolar - recent history of hypomania (mild mania, marked by elation and hyperactivity) rapid mood fluctuations Antidepressant exacerbates manic symptoms
Does lamotrigine have a short or long half life?
Long, allows for OD dosing
What mood stabilisers do we see used in Bipolar disorder?
Carbamazepine Valproate Lithium
In terms of insomnia, in what cases are short acting hypnotics preferred?
Beta blockersAntidepressantsAntipsychotics
Antimuscarinics for bladder conditions
Prior to eye operation = atropine Motion sickness = scopolamineCOPD maintenance of bronchospasms = ipratropium/tiotropiumBladder problems = Tolterodine / solifenacin/ oxybutynin/ fesoterodineParkinson like disorders = Benztropine / Trihexyphenidyl
What can accumulation of pethidine metabolites (norpethidine) result in?
neurotoxicity can lead to convulsions in overdose
Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered what?
A choice of non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine), monoamine oxidase B inhibitors (rasagiline or selegiline hydrochloride) or COMT inhibitors (entacapone or tolcapone) as an adjunct to levodopaIf these do not work, then bromocriptine/cabergoline/pergolide could be considered
Is diazepam short or long acting?
Long acting - good for if insomnia is associated with daytime anxiety
What conditions are cholinergic drugs (acetylcholinerase inhibitors used in dementia) cautioned in?
Asthma Epilepsy/history of seizures Bradycardia History of gastric ulcers
How does lithium interact with ACEis?
Risk of lithium toxicityExcretion of lithum reduced by ACEi
Antimuscarinics USE
Block muscarinic Acetylcholine receptors without specificity for subtypes M3 block results in decreased contractility of smooth muscle in lungs = bronchodilation =& reduction of mucus secretionBoth administered as inhalation treatment for maintenance bronchospasms for pt in COPDIpratropium <= nasal spray = rhinorrea = runny noseTiotropium long acting agent dosed once dailyIpratropium short acting dosed up to qdstiotropium bromide is electrically charged, not absorbed by the GI tract and does not pass the BBB
How long should a patient not drive through after an unprovoked seizure?
At least 5 weeksWith other SSRIs, it is only 1 week
Which antipsychotics commonly cause hyperglycaemia and diabetes?
ClozapineOlanzipineRisperidoneQuetiapine
MAOI interactions can persist for how long after discontinuing MAOI?
2 weeks
IV diazepam is effective in seizures but carries a high risk of what?
Thrombophlebitis
How long after starting varenicline or bupropion should the person be followed up?How does this compare with NRT?
3-4 weeks2 weeks for NRT
Once initiated on lithium therapy, how often should you measure BMI, electrolytes, eGFR and thyroid function?
Every 6 months
What class of drug is first line in depression?
SSRI
Which of the acetylcholinesterase inhibitors is used for dementia is also licensed for mild/moderate dementia associated with Parkinsons?
Rivastigmine - This has TWICE daily dosing!
What is Hyperemesis gravidarum?
Severe vomiting in pregnancy
What is first line for alcohol dependence?What would be an alternative?
Acamprosate or naltrexone in combination with a psychological intervention Alternative- disulfiram if the others are not suitable or if the patient wants this but understands the associated risks
Does ethosuximide need to be prescribed by brand?
No- Category 3
What are the side effects of methylphenidate and dexamfetamine?
CD2
What is the most commonly used beta blocker for migraine prophylaxis?
Propranolol
What is the MHRA advice regarding clozapine?
Potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileusIf constipation develops, seek immediate medical advice
How long should antidepressant treatment be continued for in generalised anxiety disorder?
At least 12 months as risk of relapse is high
What is dexamfetamine used for?
- Appetite loss, insomnia, weight loss- Increased HR and BP - Tics, Tourette’s- Growth restriction in children- monitor height and weight, allow drug free periods to grow - Psychiatric disordersMonitor the above after a dose change and then every 6 months
What is apomorphine used for?How do you manage the associated nausea and vomiting side effect?
Advanced Parkinson’s Disease - “off” episodesTo combat the associated nausea and vomiting side effects, you can use domperidone but only short term (due to QT prolongation risk with domperidone and apomorphine used together)
What is the MHRA advice regarding varenicline?
Suicidal behaviour Patients are advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood, or suicidal thoughts. Patients with a history of psychiatric illness should be monitored closely while taking varenicline.
A CO level of what suggests the person has stopped smoking or is a non-smoker?
10 ppm or less
Can lithium lower seizure threshold?
Yes
What is the MHRA advice regarding antiepileptic drugs and psychological side effects?
Associated with a small increased risk of suicidal thoughts and behaviour (can occur as early as one week after starting treatment) Seek medical advice if they develop mood changes
How does lithium interact with NSAIDs?
Risk of lithium toxicityExcretion of lithium probably reduced by NSAIDs
Zonisamide is an anti-epileptic drug. What should patients be told to avoid when on this medication?
Avoid OVERHEATING (hyperthermia) and ensure they are adequately hydrated during exercise, especially in children, as fatal cases of HEAT STROKE have been reported in children on this medication.
Which acetylcholinesterase inhibitor comes as a patch?
Rivastigmine 24 hour patch
If an epileptic patient has had a seizure whilst asleep, the patient should not drive for 12 months. What are the exceptions?
12 months even if the patient was asleep unless:- Established pattern of only having seizures when the patient is asleep over one year- If had seizures in the past awake, need to have 3 years of only having seizures asleep
What antidepressant is the safest in those at a risk of bleeding e.g. haemorrhagic stroke patients
Mirtazapine
What are the triptans (used for migraines) contraindicated in?
Heart problems, previous MI or TIA, moderate severe Hypertension or mild uncontrolled Hypertension. This is because one of the side effects is an increase in blood pressure (vasoconstrict)
What are the advantages of using peripheral dopa-decarboxylase inhibitors for Parkinson’s?
Yes
Which antidepressant class do we need to do LFT’s before starting?
TCAsThis is because you need to avoid them in severe liver disease as they can cause increased sedative effects (they cause drowsiness as it is)
What kind of drugs should be minimised in patients with cognitive impairment, such as dementia?
Antimuscarinicse.g. amitriptyline, paroxetine, solifenacin, antipsychoticsCan result in cognitive impariment
What condition are a lot of antihistamines cautioned in?
Epilepsy, glaucoma
Antidepressant treatment should be continued for at least how many weeks before you consider switching?How many weeks is this in the elderly?
4 weeks 6 weeks in the elderly as they may take longer to respond
What is aprepitant used for?
Nausea and vomiting in chemotherapy
How many migraines must someone be having per month to qualify for prophylactic migraine treatment?
2 Prophylaxis of migraines consists of beta blockers- usually Propranolol
name 5 common side effects of CNS stimulants (lisdexamfetamine/methylphenidate)?
Aggression/Irritable: mood changes Addiction Growth deceleration - anorexia Insomnia (Take OM) Nausea/Vomiting/Diarrhoea Touretts/Tics Tachycardia (methylphenidate)
Is olanzapine a first or second generation antipsychotic?
Second
What are the side effects of cholinergic drugs? (DUMB BELS)
DiarrhoeaUrinationMuscle weakness/crampsBronchospasm BradycardiaEmesisLacrimation (teary eyes) Salivation/sweating
What are the Long acting Benzodiazepines?
Chlordiazepoxide Diazepam Alprazolam Used as sedatives (diazepam for insomnia associated with anxiety), chlordiazepoxide (alcohol withdrawal)
Can varenicline be used alongside NRT?
No
Management of acute anxiety involves the use of what drug class options?
Benzodiazepine or buspirone
What severe side effect is associated with fosphenytoin (used for status epilepticus)?
Associated with severe cardiovascular reactions- asystole, ventricular fibrillation. Observe patient for at least 30 minutes after infusion
Does topimarate need to be prescribed by brand?
Based on clinical judgement - Category 2
What drugs do cigarettes interact with and require higher doses as metabolism is increased?
TheophyllineClozapineOlanzapineHaloperidolChlorpromazine Ropinerole Cinacalcet
True or false:Phenytoin is not known to cause skin pigmentation
FalseCauses yellow-brown pigmentation
Which opioid can cause convulsions in overdose?
Pethidine due to accumulation of its metabolite norpethidine and tramadol
How can chronic insomnia be managed?What are the common causes of chronic insomnia?
Usually self-limiting and short term e.g. jet lagIf a hypnotic is indicated one that is rapidly eliminated should be chosen, and only one or two doses should be given
With antiepileptic carries the risk of cleft palate following exposure in the first trimester?
Topiramate
Can tramadol lower the seizure threshold?
Breathing difficultiesDrowsiness, impaired speechSigns of opioid toxicity
A withdrawal regimen after stabilisation with methadone hydrochloride or buprenorphine should be attempted only after careful consideration. How long does complete opioid withdrawal usually take in:i) an inpatient settingii) community setting
Inpatient setting is usually 4 weeks Community setting is usually 12 weeks
For use on an emergency basis, the dose of an IM antipsychotic should be Lower or Higher than the corresponding oral dose?
Lower, due to absence of first pass metabolism with IM route
Does phenytoin have a short or long half life?
Long, allows for OD dosing
What is the deal with migraine medication and hypertension?
Ergotamine and triptans (5HT1 agonists) cause vasoconstriction: contraindicated in severe/ uncontrolled hypertension = blood vessel damage/bleeding
What electrolyte imbalance is associated with antidepressants?Which class of antidepressant is this the most common in?
Low sodiumSSRIsHyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.
Venlafaxine is generally reserved for what type of depression?
TETRAcycline antidepressant
Can patients with epilepsy drive a large goods or passenger carrying vehicle?
No only motor vehicles however they can if they haven’t had a seizure for 5 years
What is 1st line for absence seizures?What would be an alternative?
Ethosuximide or sodium valproate Lamtorogine is an alternative
What vitamin supplementation should you consider if a patient is on phenytoin?
Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.
Can TCAs cause seizures?
Yes
A deficiency in what electrolyte can lead to lithium toxicity?
ReferLithium can cause benign intracranial hypertension
Which antieplieptic has been associated with pancreatitis?
Sodium valproate
What antiepileptics are present in high amounts in breast milk? (ZELP)
ZonisamideEthosuximideLamotriginePrimidone
Which of these side effects is not associated with phenytoin?Skin coarseningGum hypertrophyHair lossOsteomalacia
Hair lossAssociated with substantial hair growth (hypertrichosis)
What class of drug is duloxetine?
Chronic
Capsaicin 0.025% cream is licensed for what?
Symptomatic relief in osteoarthritis
How often should fentanyl transdermal patches be changed?
every 72 hours
Which antipsychotics carry the highest risk of QT prolongation?
HaloperidolPimozide
In patients with a history of unstable angina or recent MI, what is the most appropriate antidepressant?
Sertraline
What is the MHRA warning associated with metoclopramide?
Risk of neurological side effects Extrapyramidal disorders and tardive dyskinesiaRecommended that it should only be prescribed for up to 5 days Especially in young adults <20 years
Should an epileptic person drive during medication changes?
UNLESS:- Established pattern of only having seizures when the patient is asleep over one year- If had seizures in the past awake, need to have 3 years of only having seizures asleep
Which parkinsons medication may exacerbate oedema and therefore should be avoided in those with HEART FAILURE?
Amantadine
Which parkinsons drug is used at a dose of 1mg daily?
Rasagaline
Which drug, used in parkinsons, should patients look out for signs of Hepatotoxicity (anorexia, nausea, vomiting, abdo pain, dark urine, pruritis)?
Tolcapone/entacapone (Red-brown urine) A catechol-o-methyltransferase inhibitor (COMT-i)
Following first remission, how long should antidepressant treatment be continued for?How long in the elderly?
At least 6 months 12 months in the elderly
Purple glove syndrome is a rare side effect of which epilepsy drug?
Phenytoin
Patients with recurrent depression should receive maintenance treatment for how long?
At least 2 years
What antieplieptic requires opthalmological monitoring/ discolouration of ocular tissue/ blue- grey discolouration of nails lips and skin?
Retigabine
How would you treat an acute episode of mania?
Narcolepsy Refractory ADHD
What are specific side effects with topiramate? Hint - eyes
Acute myopia (short sightedness) with secondary angle-closure glaucoma Encephalopathic symptoms - sedation, confusion Patients should report signs of raised intra-ocular pressure
Why is St Johns Wort such a problematic drug?
Its an enzyme inducer
What is dystonia?
Abnormal face/body movements
After how many hours of heroin use can you administer:MethadoneBuprenoprhineWhy does there need to be a gap?
At least 8 hours after for methadone 6-12 hours after for BuprenoprhineThis is to reduce the risk of precipitated withdrawal
Ipratropium and TiotropiumMOAIndicationDifference?
unlike atropine has greater CNS effect and longer duration of action- prevent motion sickness- post op n+vpatch formulation effect lasting up to 3 days
Long term use of lithium has been associated with what?
Thyroid disorders Mild cognitive and memory impairment
Which carries a higher risk of overdose during opioid replacement therapy:MethadoneBuprenoprhine
Methadone Has more severe withdrawal symptoms
Which antipsychotic is least likely to cause QT prolongation?
Aripriprazole
Using antipsychotics and what drug for dementia can increase the risk of neuroleptic malignant syndrome?
Donepezil
Is zopiclone a long or short acting hypnotic?
Shift workJet lag
During benzodiazepine withdrawal, what 3 classes of drugs should be avoided if possible (in the case of additional therapy to help with withdrawal symptoms)?
It is characterised by insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances
What class of drug is rotigotine?
Non ergot derived dopamine agonist
What is the advice regarding opioid substitution during breastfeeding?What red flag symptoms should you look out for?
Doses of methadone and buprenorphine should be kept as low as possible in breast-feeding mothers. Increased sleepiness, breathing difficulties, or limpness in breast-fed babies of mothers taking opioid substitutes should be reported urgently to a healthcare professional
How often should patients be reviewed at the start of antidepressant treatment?
Every 1-2 weeks
What should be given to alcohol dependent patients who are at risk of Wernicke’s encephalopathy?
Thiamine
How does phenytoin interact with amiodarone?
Amiodarone inhibits metabolism of phenytoin
What are the symptoms of phenytoin toxicity?
Nystagmus (involuntary eye movement), diplopia (double vision), slurred speech, ataxia, confusion, and hyperglycaemia
What is the MHRA warning associated with the sedating antihistamine hydroxyzine?
6 months
Is buprenorphine or methadone more sedating?
MethadoneFor this reason, buprenorphine may be more suitable for employed patients or those who drive, and is also safer to use if prescribed other sedating drugs However, those who experience increased anxiety during opioid withdrawal may prefer methadone
Is COMT inhibitor monotherapy licensed in Parkinson’s?
Fibrotic reactionsPulmonary- look out for SOB, coughRetroperitoneal - look out for abdominal pain and tendernessPericardial- look out for cardiac failure
What is buspirone used for?
Acute anxiety
Is moclobemide a reversible or irreversible MAOI?
Increased risk of hypotension
Patients and carers should be advised to monitor for suicidal ideation when taking this ADHD drug
Atomoxetine
What type of drug is trazadone and what is it used for?
Serotonin uptake inhibitorDepression particularly when sedation is required
Are preparations containing phenytoin sodium and phenytoin base bioequivalent?
No
What is amitriptyline used for?
No - Gabapentin does
Which antieplieptic do you need to look out for symptoms of anaemia, bruising and infection?
Lamotrigine Suggestive of BONE MARROW failure/ blood disorder
When should donepezil be given?
Once daily (Other drugs in class are BD) Give at bedtime
Why mustn’t you expose fentanyl patches to heat e.g. baths and saunas?
May increase absorption
What is the patient advice surrounding lamotrigine?
- Don’t suddenly stop treatment as needs to be tapered off gradually - Contact doctor immediately if any rash or signs of hypersensitivity- Rare - be alert for symptoms and signs suggestive of bone-marrow failure, such as anaemia, bruising, or infection.
Which antidepressants are safest in overdose?
SSRI’s These should be considered FIRST LINE in treatment of depression.
Effects of Atropine as antimuscarinic drug
AtropineScopolamineIpratropiumTiotropiumToleterodine SolifenacinBenztropineTrihexyphenidyl
How should transient insomnia be managed?
Poor sleep maintenance e.g. early morning awakening that causes daytime effectsIf an anxiolytic effect is needed during the day Diazepam
How is the pain from Mild Sickle-cell crisis managed? What if it is severe?
Just follow the pain ladder: Mild= paracetamol, NSAID, codeine Severe= Morphine
What is varenicline used for?
Smoking cessationBrand name= Champix
What should you not give in patients with bipolar?
Lithium salts Sodium valproate / valproic acid Olanzapine
Are first or second generation antipsychotics better at treating negative symptoms of schizophrenia?
Second generation
What are the side effects of Morphine?
Constipation Nausea & Vomiting (most common) Drowsiness, Dizziness Headache Mild itching Agitation Insomnia
What is the only antidepressant licensed in children?
Sodium (hyponatraemia) Therefore, be careful if on drugs that cause low sodium e.g. diuretics
Is generalised anxiety disorder a form of acute or chronic anxiety?
>4 weeks duration
If a patient on sodium valproate is experiencing nausea, vomiting, abo pain, what should you do?
Refer Could be hepatotoxicity or pancreatitis
What is the safety alert associated with injectable phenytoin?
Risk of death and severe harm from error with the prescribing/preparation/administration
True or false:For opioid addiction replacement therapy, buprenorphine has to be given every day
False Can be given on alternate days in higher doses
Abnormal dreams can occur with which NRT preparation?
Patch- this is reduced if removed before bed
Transient insomnia is caused by what?
Carbamazepine or phenytoin
Which antipsychotics are most likely to cause hyperprolactinaemia?
Risperidone, amisulpride, first generation antipsychotics
Which anti-epileptic is a TDM drug? What are the signs of toxicity?
Phenytoin Signs: Nystagmus, blurred vision, ataxia, drowsiness, ECG changes, seizures, coma Not B A D, Ecg Solves Coma
If withdrawn from an epilepsy med, how long should a patient not drive for?
No
If a patient is on an Ach inhibitor for their mild/moderate Alzheimer’s, however their condition gets more severe, what should be done?
Consider adding memantine. In this case, it can be initiated in primary care without the advice from a specialist
What is the general advice regarding monitoring patients on antipsychotics?
ECG may be required before treatmentMonitor prolactin concentration at the start of therapy, at 6 months, and then yearly.Patients with schizophrenia should have physical health monitoring (including cardiovascular disease risk assessment) at least once per year.
Name the 4 drugs used in dementia?
Donepezil Galantamine Rivastigmine (Acetylcholinesterase inhibitors) Memantine (a NMDA receptor antagonist) for severe
If a patient has persistent headaches and on lithium, what should you do?
Renal disturbancesExtrapyramidal symptomsVisual disturbancesNervous system disturbancesGI side effects
Which anti-epileptics can cause problems with vision??
Vigabatrin Topiramate Vision Topi!!
What are the common side effects of the Acetylcholinesterase inhibitors used in dementia?
Diarrhoea and vomiting, Dizziness, Headache, Hallucinations, Anorexia (weight loss) Dogs Vomit Dogs Hate Hallucinating Alone
When should lithium be stopped before major surgery?
24 hours
Treatment with domperidone should not exceed how many days?
7 days
What is the patient advice regarding diet and fluid intake if on lithium therapy?
Maintain adequate fluid intake and avoid dietary changes which reduce or increase sodium intake.
What is the patient advice regarding mirtazapine?
Blood disorders- report fever, sore throat etc
What vitamin supplementation should you consider if a patient is on sodium valproate?
Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.
Are atypical antipsychotics first or second generation antipsychotics?
Second generation
What are the serious side effects of lamotrigine?
Skin reactions: these develop within 1-8 weeks. They include serious skin reactions i.e. Steven-Johnson syndrome and toxic epidermal necrolysis Blood disorders - Patients and their carers should be alert for symptoms and signs suggestive of bone-marrow failure, such as anaemia, bruising, or infection
What is the only trimester that you can do opioid withdrawal therapy?
2nd
What is pregabalin used for in terms of pain?
10-25mg ON Max of 75mg
What should you test/measure before starting lithium treatment?
Cardiac- ECG - can prolong QT Renal function Thyroid function Blood count - can cause leukocytosis Body weight - dosing for Priadel is based on weight
What are the signs of phenytoin toxicity? (SNACHD)
Slurred speechNystagmusAtaxiaConfusionHyperglycaemiaDiplopia
What antiepileptics are mainly associated with antiepileptic hypersensivitiy syndrome?(CP3L)
CarbamazepinePhenytoinPhenobarbitalPrimidoneLamotrigine In first 8 weeks of starting discontinue immediately
Hair loss with regrowth of curly hair is a rare effect of which drug?ValproatePhenytoinCarbamazepineLamotrigine
Valproate
What is the MHRA warning associated with domperidone?
Risk of cardiac side effects QT prolongationMax treatment duration should not normally exceed 1 week
In terms of insomnia, in what cases are long acting hypnotics preferred?
Sleep onset insomniaWhere sedation the following day is not desirableElderly Short term insomnia
What is a main side effect of lamotrigine?What are the risk factors of this?
Hypersensitivity syndrome.Serious skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis have developed (especially in children); most rashes occur in the first 8 weeks. Risk factors include concomitant use of valproate, too high dose or too rapid dose increase
Has diazepam got a short or long half life?
Long half life
What Parkinson’s Disease medicine can exacerbate oedema and cautioned in congestive heart failure?,
Amantadine
What class of drug is mirtazapine?
Psychological therapy should be considered initiallyIf history of moderate or severe depression, consider antidepressant therapy
What is 1st line for myoclonic seizures?What would be alternative options?
Sodium valproate Topiramate or levetiracetam
When should lithium samples be taken?
12 hours post dose
Do brief febrile convulsions need any treatment?
No, may give paracetamol to reduce fever However, if prolonged (>5 mins) or recurrent, treat as epileptic seizure.
In Hyperemesis gravidarum what vitamin supplementation should be considered?
Thiamine to reduce the risk of Wernicke’s
3 types oc holinergic antagonists
Eye - relaxation ciliary muscle = dilation of pupil, not responsive to light, can be used prior to eye surgery but due to long duration of action (lasting days) cyclopentolate or tropicamide is preferred (lasting hours)GI - blocks M3 Rec reducing gut motility, prolonging transit time and gastric emptyingHeart - blocks M2 receptors on SA/AV => tachycardia (^30-40bpm)Salivary/sweat/lacrimal glands = dry mouth, dry skin and ultimately increase in body temperature
True or false:Naloxone only partially reverses the effects of buprenorphine
Hypokalaemia and hypomagnesaemia
What class of antipsychotics are hepatotoxic and can therefore precipitate coma?
Phenothiazines(Chlorpromazine, Promazine, Pipotiazine, Fluphenazine, Trifluoperazine, flupentixol)
What are the side effects of nicotine containing preparations?
Local irritation GI disturbances Dry mouth if spray, lozengePalpitations - rarely with patches and oral spray Hot flushes
If after initial treatment of IV lorazepam and there is no response after 25 mins, what should be used?
Phenytoin/phenobarbital/fosphenytoinIf this does not work- anaesthesia
What are the signs of lithium toxicity?
GI disturbances- vomiting and diarrhoea Visual disturbances - nystagmus (involuntary movement of the eyes) Renal - Polyuria - increased urination + thirst, AKI, renal failure (esp due to dehydration - ensure fluid intake) CNS disturbances- confusion, drowsiness, lack of coordination, memory imp, restless, tremor Hypernatraemia Cardiac arrhythmias Coma
What does management (treatment) of anxiety usually involve?
A benzodiazepine (with opioids inc risk of CNS depression and with methadone risk for up to 2weeks after) or Buspirone (if on CYP3A4 inhib reduce dose to 2.5mg BD) - contraindicated in epilepsy Chronic anxiety - antidepressant- usually an SSRI- usually escitalopram, paroxetine or sertraline
What conditions can lamotrigine exacerbate?
Parkinson’s DiseaseMyoclonic seizures
What is the anti-emetic of choice in parkinsons?
Domperidone as it does not cross the BBB
A self adhesive capsaicin patch 8% is licensed in what?
Treatment of peripheral neuropathic pain in non-diabetic patients
Which antipsychotic drug should be handled with care?
Chlorpromazine - Causes contact sensitisation (irritates skin)
For short term relief of anxiety, hypnotics should not be used for longer than what?
Yes
How does clozapine interact with smoking?
Smoking breaks down clozapine so a higher dose may be needed
Which antidepressant class is associated with a high rate of fatality?
TCAsCardiovascular and epileptogenic effects Cautioned in those with a high risk of suicide- consider reduced supply on prescription so there are more regular reviews
Which of the following can you titrate faster:MethadoneBuprenoprhine
Buprenoprhine - can titrate within 1 weekMethadone can take several weeks
Which antiepileptic drug is associated with visual field defects?
Vigabatrin visual = Vi
In terms of anxiety, what are benzodiazepines indicated for?
Short term relief of severe anxiety (2-4 weeks) - Not for mild anxiety!
What is the patient advice surrounding phenytoin?
Can cause agranulocytosis Recognise signs of blood or skin disorders- report if mouth ulcer, bruising, bleeding develops Antiepileptic sensitivity syndrome
What side effect can antiparkinsons drugs cause in the elderly?
Confusion + drowsy (so increased risk of falls)
Seizures lasting longer than 5 minutes should be treated with what benzodiazepine?What should you monitor?
IV lorazepam - can repeat once after 10 minutes if response fails Monitor for hypotension and respiratory depression
How does phenytoin and levothyroxine interact?
Phenytoin= enzyme inducer so reduces drug concentrationIncreased risk of hypothyroidism
If a patient on methadone becomes pregnant, should they stop the methadone?
No Therapy should be continued 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.
Sevredol, MST continus and Oramorph are all brands of what?
Morphine
Lithium toxicity is made worse by sodium depletion, therefore what drugs should be avoided?
B2 agonists (salbutamol/terbutaline) Inhaled corticosteroids diuretic (loop - furosemide) (TLD - indapamide) NSAIDs (nephrotoxic too) PPIs Steroids SSRIs TCAs
Is withdrawal is more common with the short or long acting benzodiazepines?
Short acting
Can ondansetron cause QT prolongation?
Yes
If a whole pack of sodium valproate cannot be dispensed, what must be put on the part pack?
Warning sticker
Hypnotics should not be used for more than _____ for short term insomnia?
3 weeks
If extra-pyramidal side effects are a concern, should first or second generation antipsychotics be prescribed?
Second generation
How should vomiting in pregnancy be managed?
Morning sickness- anti-emetic not routinely recommended- home remedies such as ginger. 1st trimester and mild - do not treat, lifestyle changes and avoid triggers/ pressure bands If severe: short term antihistamine e.g. promethazine (metoclopramide/prochlorperazine alternative)
Does phenobarbital have a short or long half life?
Long, allows for OD dosing
What kind of toxicity is caused by tolcapone?
No Used as an adjunct to levodopa
What role do beta blockers play in anxiety?
Diazepam - long actingSingle dose at night
How long before the target smoking quit date should varenicline and bupropion be started?
7-14 days before
Ethosuximide is used for what type of seizures?
Absence Myoclonic
Which antidepressant drug is associated with weight gain?!
MIRTAZEPINE(Tetracyclic)
What S/E has been linked to antidepressant use
Suicidal ideation (especially if hx of this) Hyponatraemia Prolong QT Bleeding risk esp with NSAIDs/ACGs/Antiplatelets Reduced seizure threshold Serotonin syndrome is also a risk, particularly with MAOIs
What pre-treatment screening is needed in Chinese and Thai patients when starting phenytoin and carbamazepine- why?
HLB-B*1502 allele - have an increased risk of Steven-Johnson syndrome
Hair loss is a common side effect of what Parkinsons Medicine?
Selegiline
Treatment with metoclopramide should not exceed how many days?
5 days
Neurotransmitters and effectson Mood and Cognitive function
main agent is nicotine - cig smoke; stimulates and later represses autonomic ganglia. Cholinergic agonist but also functional antagonist as it can stimulate and block cholinergic function. Acts on nicotinic rec or parasympathetic and sympathetic autonomic ganglion, ^release of neurotransmitters such as dopamine, norepinehprine and serotonin.
True or false:The use of antidepressants has been linked with suicidal thoughts and behaviour
TRUE
Does buprenorphine or methadone require a shorter drug-free period (before naltrexone is needed for relapse prevention)?
Buprenorphine
What is an advantage of domperidone over metoclopramide?
Less readily crosses the BBB so less likely to cause sedation and dystonic reactions
Which antipsychotics are least likely to cause weight gain?
AriprazoleHaloperidolAmisulpride
What monitoring does clozapine require?
Monitor leucocyte and differential blood counts. Clozapine requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly as part of the clozapine patient monitoring serviceBlood lipids and weight at baselineFASTING blood glucose baselineBaseline prolactin
What is the most effective drug used in motion sickness?
Hyoscine Hydrobromide Promethazine also used if sedative effect needed Domperidone, metoclopramide are ineffective! (do not give Domp to <12 years and meto <18 years)
How old do you have to be to purchase codeine OTC? What age must children be to have codeine prescribed?
18 or over to purchase Only for use in children over 12. 12-18 years: max dose 240mg daily (same as adults) at intervals no less than 6 hours. Treatment should be limited to 3 days
What groups of patients are short acting benzodiazepines more suitable for?
Short acting
Why is it important to maintain good oral hygiene if taking phenytoin?
Can cause gingival hyperplasia
What is diplopia?
Double vision
What is Buspirone?
A serotonin receptor agonist used for anxiety
What is primidone used for?
Essential tremor Epilepsy
Does valproate need to be prescribed by brand?
Based on clinical judgement - Category 2
What is methylphenidates mechanism of action?
N-Methyl-D-Aspartate (NMDA) antagonist (hence the methyl!) it has a neuro-protective effect
If drug therapy is required for a Parkinson’s Disease patient who develops postural hypotension, what is considered as first line?
Midodrine
Panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder are treated with what drug class?
SSRIs
In what 3 circumstances should phenytoin treatment be discontinued?
Signs of toxicity (NDSACH - Nystagmus, dipolopia, slurred speech, ataxia, confusion, hypreglycaemia) Rash Hepatoxicity
What antibiotic class can result in carbamazepine toxicity?
Macrolides
How does phenytoin interact with warfarin?
Phenytoin accelerates metabolism of warfarin
What is lithium used for?
Treatment and prophylaxis of: Mania, Bipolar disorder, Recurrent depression, Aggressive/self harming behaviour
If vomiting during the first trimester of pregnancy is severe and requires drug therapy, what is used?
Short term antihistamine e.g. promethazine
Carbamazepine commonly causes what electrolyte imbalance?
Hyponatraemia
For opioid addiction, what can be used for opioid maintenance therapy?
Buprenorphine or methadone
What kind of effect can happen as a result of taking benzodiazepines?
Paradoxical effectsA paradoxical increase in hostility and aggression may be reported by patients taking benzodiazepines
Which anti epileptics could cause agranulocytosis?
Ethosuximide Look out for fever, mouth ulcers, bruising, bleeding Phenobarbital possibly?
What severe skin reaction has Lamotrigine been associated with?
Stevens Johnson syndrome This is where cell death/ necrosis occurs causing the epidermis to separate from the dermis. Usually begins with fever, ulcers, sore throat
Which anti-epileptic requires monitoring of ECG and BLOOD PRESSURE with intravenous use?
Phenytoin
How does phenytoin interact with St John’s Wort?
St. Johns Wort (an enzyme inducer) reduces plasma conc. of phenytoin
Which drug, used in parkinsons, can colour urine reddish-brown?
Entacapone
When starting carbamazepine, what ethnicity of people require testing for the HLA-B*1502 allele and therefore may be more at risk of Stevens Johnson Syndrome?
Thaiand Han Chinesepeople of chinese ethnicity are most at risk of genetic polymorphisms of the CYP2D6 enzyme
True or false:Clozapine patients must be registered with a clozapine patient monitoring service
TRUE
What do you need to consider in terms of the dose in patients on oral antipsychotics that require a change to IM?
IM bypasses first pass metabolism so consider a lower dose than that of the oral
When should clozapine be used in schizophrenia?
When 2 or more antipsychotics have not worked One of the antipsychotics tried must have been a second generation All the tried antipsychotics must have been tried each for at least 6-8 weeks
Is lithium use associated with hyper or hypothyroidism?
Hypothyroidism
What are the common SEs of pregabalin (used for neuropathic pain)?
Appetite changes Blurred vision Disturbance in muscle control/ movement
Which antieplieptic has been associated with the serious skin rash, Steven Johnsons syndrome?
LamotrigineUsually in first 8 weeks of treatment
What hypnotics should be avoided in the elderly?
Benzodiazepines and Z drugs - the elderly are more at risk of becoming confused and falling and also becoming dependant
What is 1st line for tonic-clonic seizures? What would be an alternative if this is unsuitable? What is the problem with this?
Sodium valproate or lamotrigine Carbamazepine is an alternative however may exacerbate myoclonic seizures
Patients should receive an antipsychotic for how many weeks before it is deemed ineffective?
4-6 weeks
Why do parkinsons drugs come as combination preparations e.g. Co-careldopa, Co-benedlopa
PD= decrease in dopamine in the brain so the brain cannot control movement Dopamine itself is not lipophilic enough to cross the BBB. So we give a dopamine pre-cursor: Levodopa. This is very lipophilic which helps DA cross the BBB. But the problem is it also gets everywhere in the periphery and causes EPSE’s. So we give it in combo with a periphery-specific dopamine decarboxylase inhibitor in these combo preps, so that it doesn’t get converted to its active form in the periphery.
How does phenytoin interact with cimetidine?
Cimetidine inhibits the metabolism of phenytoin
Sinemet absorption is reduced when taken with foods high in what nutrient?ProteinFat Carbohydrates
Protein as it competes with levodopa for absorption
Is temazepam long or short acting?
Short acting
True or false:Diazepam IM or suppositories should be used for status epilepticus
False- absorption is too slow
Following successful opioid withdrawal treatment in the management of addiction, how long should the patient be followed up for?
6 months at least
What are the specific side effects with clozapine?
NAME?
Why should you monitor patients using fentanyl patches if they have a fever?
Increased absorption of drug
What is the dose of codeine in adults per day?
30-60mg every 4 hours PRN MAX DOSE: 240mg per day (8 tablets- same as paracetamol)
Which Benzo is indicated before dental surgery?
TemazepamTake 30-60 mins beforeAlso indicated for insomnia- take 30-60 mins before bed time Has a medium duration of action so good for these two things
If changing from fluoxetine to MAOI, what is the period of time you can start this after fluoxetine has been stopped?What about starting an MAOI from other SSRIs?
SNRI
Can SSRIs lower seizure threshold?
Fluoxetine
What schedule is methylphenidate (Concerta)?
Reduce diazepam dose, usually by 1–2 mg every 2– 4 weeksFor high doses- reduce by up to one tenth every 1-2 weeks
What migraine medication is not licensed for use in the elderly??
The triptans Remember Sumitriptan only licensed for 18y-65y OTC.
Morphine is the opioid of choice for severe pain in palliative care. How often is it given?
Given every 4 hours(or 12 or 24 hours if its MR)
What antiepileptics carry a high risk of withdrawal symptoms?
Phenobarbital Primidone
Which anti-epileptic do we need to monitor plasma bicarbonate levels due to risk of metabolic acidosis?
Zonisamide Metabolic acidosis is an increase in plasma acidity
What are the signs of lithium toxicity? (REVNG)
Antidepressants
What may increase absorption of fentanyl patches?
Fever (hot skin) Exposure to external heat
Can e-cigarettes be supplied by smoking cessation services?
No
What antiepileptics inhibit sucking reflex in breast feeding?
Phenobarbital Primidone
How does phenytoin interact with fluoxetine?
Phenytoin concentration increased by fluoxetine
If an epileptic patient becomes pregnant, what supplement is recommended alongside their pregnancy, especially in the first trimester?
Folate supplementation to prevent neural tube defects - folic acid 5mg OD
What is classed as chronic anxiety?
More severe
What is the MHRA advice regarding gabapentin?
Risk of severe respiratory depression
What is the max dose of gabapentin a day?
150mg daily in divided doses
How long should bipolar therapy be for?
For at least two years from the last manic episode and up to five years if the patient has risk factors for relapse.
What two electrolyte imbalances should be corrected before using 5HT3 antagonists e.g. ondansetron?
Domperidone
What would be the starting dose of pregabalin for neuropathic pain?
600mg
Which is stronger, methadone oral solution or linctus?
Oral solution (1mg/1ml) is 2.5 x stronger than the linctus!
For rivastigmine patches, you should avoid using the same area on the body for how many days?
14 days
