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My Pham Notes > Chapter 4: Nervous system > Flashcards

Chapter 4: Nervous system Flashcards

1
Q

Which of the acetylcholinesterase inhibitors is used for dementia is also licensed for mild/moderate dementia associated with Parkinsons?

A

Rivastigmine - This has TWICE daily dosing!

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2
Q

When should donepezil be given?

A

Once daily (Other drugs in class are BD)

Give at bedtime

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3
Q

What conditions are cholinergic drugs (acetylcholinerase inhibitors used in dementia) cautioned in?

A

Asthma
Epilepsy/history of seizures
Bradycardia
History of gastric ulcers

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4
Q

What are the common side effects of the Acetylcholinesterase inhibitors Donepezil hydrochloride
Galantamine used in dementia?

A

Diarrhoea and vomiting, Dizziness, Headache, Hallucinations, Anorexia (weight loss)

Dogs
Vomit
Dogs
Hate
Hallucinating
Alone

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5
Q

Name the 4 drugs used in dementia?

A

Donepezil Galantamine Rivastigmine (Acetylcholinesterase inhibitors)
Memantine (a NMDA receptor antagonist) for severe

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6
Q

Which acetylcholinesterase inhibitor comes as a patch?

A

Rivastigmine 24 hour patch

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7
Q

Short acting benzodiazepines?

A

Midazolam - Used for epileptic seizures (SE) and febrile convulsions due to its fast onset

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8
Q

what are the intermediate acting benzodiazepines

A

Clonazepam Lorazepam Oxazepam Temazepam

CLOT (Hence why some of these are used for agitation in our patients: As long-acting ones increase drowsiness)

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9
Q

What are the Long acting Benzodiazepines?

A

Chlordiazepoxide Diazepam nitrazepam

Used as sedatives (diazepam for insomnia associated with anxiety), chlordiazepoxide (alcohol withdrawal)

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10
Q

What is Buspirone?

A

A serotonin receptor agonist used for anxiety

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11
Q

Name some medication used in ADHD?

A

CNS Stimulants:
- Methylphenidate (Ritalin (IR), Concerta (SR), Medikinet, Equasym)

  • Dexamfetamine Lisdexamfetamine (prodrug of dexamfetamine, Elvanse, Elvanse Adult)

Atomoxetine

Clonidine (specialist)

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12
Q

name 5 common side effects of CNS stimulants (lisdexamfetamine/methylphenidate)?

A

Aggression/Irritable: mood changes
Addiction
Growth deceleration - anorexia
Insomnia (Take OM)
Nausea/Vomiting/Diarrhoea
Touretts/Tics

Tachycardia (methylphenidate)

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13
Q

When should antidepressants be avoided in bipolar?

A

In MANIC phase

Rapid cycling bipolar - recent history of hypomania (mild mania, marked by elation and hyperactivity) rapid mood fluctuations

Antidepressant exacerbates manic symptoms

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14
Q

What mood stabilisers do we see used in Bipolar disorder?

A

Carbamazepine
Valproate
Lithium

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15
Q

When should lithium be taken?

A

At night- blood test needs to be 12 hours post-dose and blood test usually in the morning

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16
Q

Lithium toxicity is made worse by sodium depletion, therefore what drugs should be avoided?

A

B2 agonists (salbutamol/terbutaline)
Inhaled corticosteroids
diuretic (loop - furosemide) (TLD - indapamide)
NSAIDs (nephrotoxic too)
PPIs
Steroids
SSRIs
TCAs

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17
Q

Signs of lithium toxicity?
Dehydration
Hyponatraemia

A

Within therapeutic range:
Nausea, vomiting, diarrhoea, weight gain, polyuria, QT prolongation, HYPERglycaemia, HYPOthyroidism

Severe:
Hand TREMOR, slurred speech, irritability, stupor (numbness), seizures, nephrotoxicity, arrhythmias, coma, HYPERnatraemia

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18
Q

Can lithium be used in pregnancy?

A

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

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19
Q

What are the two different Lithium salts?

A

Lithium Carbonate: Camcolit, Priadel, Liskonium tablets

Lithium Citrate: Li-liquid, Priadel liquid (citrate only comes as a liquid)

Rx by brand

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20
Q

Why is it important to stick to the same brand of lithium?

A

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

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21
Q

In what patients are Dexamfetamine and Lisdexamfetamine cautioned

A

Tics & Tourettes
History of epilepsy
Mild hypertension
Susceptibility to angle closure glaucoma

May also cause growth restriction in children

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22
Q

Patients and carers should be advised to monitor for suicidal ideation when taking this ADHD drug

A

Atomoxetine

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23
Q

Which antipsychotic drug should be handled with care?

A

Chlorpromazine - Causes contact sensitisation (irritates skin)

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24
Q

Hyponatreamia has been linked to all antidepressants, but is more likely with which class?

A

SSRIs

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25
Q

What S/E has been linked to antidepressant use

A

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

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26
Q

How long after discontinuation of MAOIs can interactions still occur

A

Up to 2 weeks. That’s why a withdrawal period is required.

Moclobemide is short acting so does not require a withdrawal/washout period

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27
Q

What withdrawal period is required for fluoxetine

what about other SSRIs

A

5 weeks

Other SSRIs: Up to 2 weeks

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28
Q

Which SSRIs have the greatest risk of withdrawal syndrome

A

Paroxetine and Venlafaxine (SNRI) due to their shorter half lives

dose to be decreased gradually over at least 4 weeks

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29
Q

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?

A

Impulse control disorders - gambling, shopping

Sudden onset of sleepiness: avoid driving

Hypotensive reactions during first few days of treatment

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30
Q

Which antiemetic is associated with a small increased risk of cardiac effects?

A

Domperidone

10 mg 3 times a day, 7 days

QTc prolongation Treatment should not exceed 1 week

Do not use in <12 years/<35kg as no evidence of effectiveness

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31
Q

What antiemetic is associated with an increased risk of neurological effects, such as tardive dyskinesia and EPSEs?

A

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)

10 mg, repeated up to 3 times daily

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

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32
Q

Can Fentanyl be used in opioid naive patients

A

NO

Manufacturer advises use only in opioid tolerant patients due to risk of respiratory depression

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33
Q

What schedule is tramadol?

A

Schedule 3 CD No Reg

Exempt from safe custody

Prescription requirements and 28 day validity still stand

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34
Q

Which anti epileptic should patients be warned to look out for signs of fever, rash, mouth ulcers, bruising, bleeding?

A

Carbamazepine

Signs of blood, hepatic or skin disorders

do not use for absence or myoclonic seizures

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35
Q

What has IV infusion of Fosphenytoin been associated with?

A

Severe cardiovascular reactions

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36
Q

What severe skin reaction has Lamotrigine been associated with?

A

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

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37
Q

Which antiepileptic do we need to be careful with in liver impairment?

A

Sodium valproate

Monitor LFTs

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38
Q

Which anti-epileptic is a TDM drug? What are the signs of toxicity?

A

Phenytoin (Blood or skin disorders)
Vit D

Signs: Nystagmus, blurred vision, ataxia, drowsiness, ECG changes, seizures, coma, hyperglycaemia

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39
Q

Which antieplieptic could be a problem in patients with glaucoma?

A

Topiramate

Associated with acute myopia (short sightedness with secondary angle closure glaucoma

SE: kidney stones

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40
Q

Which antiepileptic drug is associated with visual field defects?

A

Vigabatrin

visual = Vi

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41
Q

Which drug used to aid smoking cessation should be discontinued if the person becomes agitated, depressed or suicidal?

A

Varenicline

This is a selective nicotine receptor partial agonist

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42
Q

Which is stronger, methadone oral solution or linctus?

A

Oral solution (1mg/1ml) is 2.5 x stronger than the linctus!

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43
Q

Which antidepressants are safest in overdose?

A

SSRI’s

These should be considered FIRST LINE in treatment of depression.

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44
Q

Which antidepressant is safest to use in a patient with unstable angina/ had a recent Myocardial Infarction?

A

Sertraline (SSRI)

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45
Q

Why is St Johns Wort such a problematic drug?

A

Its an enzyme inducer

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46
Q

Antidepressants can cause hyponatreamia. What are the symptoms of this?

A

Confusion, Drowsiness, Convulsions

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47
Q

What does management (treatment) of anxiety usually involve?

A

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

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48
Q

How do TCA’s work?

A

Block the reuptake of both noradrenaline and serotonin, although each to different extents.

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49
Q

Which TCA is frequently associated with hepatotoxicity?

A

Lofepramine

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50
Q

Which TCA should be initiated by a specialist?

A

Dosulepin

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51
Q

What are the irreversible and reversible MOAI

A

Phenelzine, Isocarboxazid, Tranylcypromine (irreversible inhibition)

Moclobemide (reversible inhibition)

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52
Q

For use on an emergency basis, the dose of an IM antipsychotic should be Lower or Higher than the corresponding oral dose?

A

Lower, due to absence of first pass metabolism with IM route

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53
Q

Are antipsychotics better at treating positive or negative symptoms?

A

Positive

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54
Q

Which antipsychotic can cause contact sensitisation so should be handled with care?

A

Chlorpromazine

tablets should NOT BE CRUSHED

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55
Q

Which antipsychotics may need their dose adjusting according to smoking status during therapy?

A

Clozapine, Haloperidol, Chlorpromazine and Olanzapine

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56
Q

What class of antipsychotics are hepatotoxic and can therefore precipitate coma?

A

Phenothiazines(Chlorpromazine, Promazine, Pipotiazine, Fluphenazine, Trifluoperazine, flupentixol)

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57
Q

What is the difference between haloperidol and haloperidol decanoate? Same with zuclopenthixol and zuclopentixol decanoate?

A

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.)

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58
Q

What side effect can antiparkinsons drugs cause in the elderly?

A

Confusion + drowsy (so increased risk of falls)

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59
Q

Which antimuscarinic, used for drug-induced parkinsons, should be taken with or after food?

A

Trihexyphenidyl hydrochloride

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60
Q

Which drug, used in parkinsons, can colour urine reddish-brown?

A

Entacapone

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61
Q

Which drug, used in parkinsons, should you avoid taking iron-containing products at the same time of day??

A

Entacapone, as it may form CHELATES WITH IRON, affecting its absorption

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62
Q

Which drug, used in parkinsons, should patients look out for signs of Hepatotoxicity (anorexia, nausea, vomiting, abdo pain, dark urine, pruritis)?

A

Tolcapone/entacapone (Red-brown urine)

A catechol-o-methyltransferase inhibitor (COMT-i)

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63
Q

What is the anti-emetic of choice in parkinsons?

A

Domperidone as it does not cross the BBB

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64
Q

Which anti-emetic is of value in the treatment of nausea and vomiting associated with cytotoxic use in cancers?

A

Ondansetron

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65
Q

What is the most effective drug used in motion sickness?

A

Hyoscine Hydrobromide

Promethazine also used if sedative effect needed

Domperidone, metoclopramide are ineffective! (do not give Domp to <12 years and meto <18 years)

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66
Q

What condition are a lot of antihistamines cautioned in?

A

Epilepsy, glaucoma

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67
Q

How should vomiting in pregnancy be managed?

A

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)

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68
Q

How is the pain from Mild Sickle-cell crisis managed? What if it is severe?

A

Just follow the pain ladder: Mild= paracetamol, NSAID, codeine
Severe= Morphine

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69
Q

A patient on warfarin requests a pack of aspirin 300mg OTC to treat a headache. What do you do?

A

Increased risk of bleeds when aspiring given with coumarins due to its anti-platelet effect.

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70
Q

What is the max strength of codeine that you can buy OTC?

A

128mg Present in Solpadeine Max and Panadol Ultra

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71
Q

What are the side effects of Morphine?

A

Constipation
Nausea & Vomiting (most common)
Drowsiness, Dizziness
Headache
Mild itching
Agitation
Insomnia

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72
Q

Morphine is the opioid of choice for severe pain in palliative care. How often is it given?

A

Given every 4 hours(or 12 or 24 hours if its MR)

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73
Q

How often should fentanyl transdermal patches be changed?

A

every 72 hours

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74
Q

Which analgesics have been associated with psychiatric reactions/ hallucinations?

A

Tramadol

Pentazocine (avoid this after a myocardial infarction)

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75
Q

Why are opioids cautioned in respiratory disease such as COPD and acute attacks of asthma

A

This is because of their potential to produce respiratory depression

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76
Q

Long term use of opioids can result in

A

Hypogonadism (sexual dysfunction)
Adrenal insufficiency
Hyperalgesia: abnormal pain sensitivity (develop tolerance)

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77
Q

What is the dose of codeine in adults per day?

A

30-60mg every 4 hours PRN

MAX DOSE: 240mg per day (8 tablets- same as paracetamol)

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78
Q

Codeine Max dose- adults

A

240mg per day (8 tablets- same as paracetamol)

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79
Q

How old do you have to be to purchase codeine OTC? What age must children be to have codeine prescribed?

A

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

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80
Q

The ability to metabolise codeine into morphine can vary greatly between individuals. Ultra rapid metabolisers are more susceptible to toxicity. What enzyme is involved?

A

CYP2D6

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81
Q

Why should codeine be avoided in breast feeding mothers?

A

Mothers vary in their capacity to metabolise codeine to morphine, risk of morphine overdose in the infant. This does not apply to dihydrocodeine

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82
Q

Why aren’t fentanyl transdermal patches suitable for patients requiring rapid titration of dose/ changing doses all the time?

A

Due to the long time to steady state (24-72 hours)

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83
Q

What may increase absorption of fentanyl patches?

A

Fever (hot skin) Exposure to external heat

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84
Q

Sevredol, MST continus and Oramorph are all brands of what?

A

Morphine

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85
Q

What CD schedule is Morphine sulphate solution, 2mg/ml?

A

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

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86
Q

What can accumulation of pethidine metabolites (norpethidine) result in?

A

neurotoxicity

can lead to convulsions in overdose

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87
Q

what is the interaction with tramadol and alcohol

A

Alcohol can increase the nervous system side effects of tramadol such as dizziness, drowsiness, and difficulty concentrating.

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88
Q

What migraine medication is not licensed for use in the elderly??

A

The triptans

Remember Sumitriptan only licensed for 18y-65y OTC.

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89
Q

What are the triptans (used for migraines) contraindicated in?

A

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)

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90
Q

What side effects can Triptan’s cause which can lead to medication discontinuation?

A

sensations of tingling, heat, pressure, tightness in the body

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91
Q

What is the max daily dose of OTC sumatriptan
(previously diagnosed migraine)?

A

comes as 50mg tabs OTC: Max 2 daily (100mg)

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92
Q

What can we use to treat cluster headache?

A

Sumatriptan SC injection
or Zolmitriptan

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93
Q

How many migraines must someone be having per month to qualify for prophylactic migraine treatment?

A

2

Prophylaxis of migraines consists of beta blockers- usually Propranolol

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94
Q

Can patients with epilepsy drive a large goods or passenger carrying vehicle?

A

No only motor vehicles

however they can if they haven’t had a seizure for 5 years

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95
Q

What criteria must an epileptic meet if they want to drive their car?

A

-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

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96
Q

What risk does Topiramate carry in terms of harm to foetus?

A

Risk of Cleft palate (cleft lip)

Topira - palate

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97
Q

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?

A

Yes, whether on medication or not, she still needs to

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98
Q

What drug should be used to manage febrile convulsions?

A

Brief febrile convulsions (resulting from high temp/ fever) require no specific treatment, just anti-pyretic medication- paracetamol!!

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99
Q

What do patients and carers need to look out for in those taking carbamazepine and phenytoin?

A

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)

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100
Q

Which anti epileptics could cause agranulocytosis?

A

Ethosuximide Look out for fever, mouth ulcers, bruising, bleeding Phenobarbital possibly?

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101
Q

Which antieplieptic has been associated with the serious skin rash, Steven Johnsons syndrome?

A

Lamotrigine
Usually in first 8 weeks of treatment

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102
Q

Which antieplieptic do you need to look out for symptoms of anaemia, bruising and infection? Bone marrow + blood disorder

A

Lamotrigine Suggestive of BONE MARROW failure/ blood disorder

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103
Q

Which anti-epileptic requires monitoring of ECG and BLOOD PRESSURE with intravenous use?

A

Phenytoin

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104
Q

What is the target plasma concentration of the TDM drug phenytoin?

A

10-20mg/L

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105
Q

What are the signs of phenytoin toxicity?

A

Nystagmus (uncontrolled eye movement) Diplopia (double vision) Slurred speech Ataxia (uncontrolled body movement) Confusion HYPERglyceamia

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106
Q

In what 3 circumstances should phenytoin treatment be discontinued?

A

Signs of toxicity (NDSACH - Nystagmus, dipolopia, slurred speech, ataxia, confusion, hyperglycaemia)
Rash
Hepatoxicity

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107
Q

Coarsened facial appearance, acne, weight loss, constipation, dizziness, mouth tenderness, headache, nausea All side effects of?

A

Phenytoin

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108
Q

What antieplieptic requires opthalmological monitoring/ discolouration of ocular tissue/ blue- grey discolouration of nails lips and skin?

A

Retigabine

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109
Q

Which anti-epileptic is particularly associated with hepatic dysfunction and what are the symptoms?

A

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
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110
Q

Which antieplieptic has been associated with pancreatitis?

A

Sodium valproate

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111
Q

Should we routinely monitor plasma valproate levels?

A

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

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112
Q

Which anti-epileptics can cause problems with vision??

A

Vigabatrin
Topiramate

Vision Topi!!

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113
Q

In terms of anxiety, what are benzodiazepines indicated for?

A

Short term relief of severe anxiety (2-4 weeks) - Not for mild anxiety!

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114
Q

Hypnotics should not be used for more than _____ for short term insomnia?

A

3 weeks

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115
Q

What hypnotics should be avoided in the elderly?

A

Benzodiazepines and Z drugs - the elderly are more at risk of becoming confused and falling and also becoming dependant

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116
Q

Which parkinsons medication may exacerbate oedema and therefore should be avoided in those with HEART FAILURE?

A

Amantadine

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117
Q

Which parkinsons medication may cause hair loss (alopecia) and hypersexuality as a side effect?

A

Selegiline (MAO-Bi) - Also gets converted to amphetamines so DRUGS AND DRIVING

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118
Q

What is the deal with migraine medication and hypertension?

A

Ergotamine and triptans (5HT1 agonists) cause vasoconstriction: contraindicated in severe/ uncontrolled hypertension = blood vessel damage/bleeding

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119
Q

When should SSRI’s be taken? What about TCA’s? What about Mirtazepine?

A

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

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120
Q

At what strength does Oramorph solution turn from a Schedule 5 CD to a schedule 2?

A

Strengths exceeding 13mg/ 5ml

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121
Q

Zonisamide is an anti-epileptic drug. What should patients be told to avoid when on this medication?

A

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.

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122
Q

Which anti-epileptic is cautioned in patients with a LOW BODY WEIGHT?

A

Zonisamide - Monitor weight throughout treatment as fatal cases of weight loss reported in children.

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123
Q

Which anti-epileptic do we need to monitor plasma bicarbonate levels due to risk of metabolic acidosis?

A

Zonisamide Metabolic acidosis is an increase in plasma acidity

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124
Q

What should patients on Bromocriptine for parkinsons be advised with regards to OTC drugs?

A

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.

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125
Q

Why do parkinsons drugs come as combination preparations e.g. Co-careldopa, Co-benedlopa

A

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.

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126
Q

What are the common SEs of pregabalin (used for neuropathic pain)?

A

Appetite changes
Blurred vision
Disturbance in muscle control/ movement

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127
Q

Early treatment with____ can delay the need for levodopa therapy in Parkinsons

A

Selegiline

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128
Q

Which parkinsons drug is used at a dose of 1mg daily?

A

Rasagaline

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129
Q

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?

A

Act centrally by blocking the chemoreceptor trigger zone

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130
Q

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?

A

Piperazines, Prochlorpromazine, Fluphenazine, Trifluoperazine, chlorpromazine, promazine, triflupromazine

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131
Q

Which antidepressant drug is associated with weight gain?!

A

MIRTAZEPINE(Tetracyclic)

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132
Q

Which opioid can cause convulsions in overdose?

A

Pethidine due to accumulation of its metabolite norpethidine

and tramadol

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133
Q

What is methylphenidates mechanism of action?

A

N-Methyl-D-Aspartate (NMDA) antagonist (hence the methyl!) it has a neuro-protective effect

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134
Q

Which Benzo is indicated before dental surgery?

A

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

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135
Q

Which antidepressant class do we need to do LFT’s before starting?

A

TCAs

This is because you need to AVOID them in severe liver disease as they can cause increased SEDATIVE effects (they cause drowsiness as it is)

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136
Q

Surely CNS stimulants Indicated for ADHD would make it worse?

A

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

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137
Q

What conditions are stimulants (methylphenidate, lisdexamfetamine, atomoxetine etc) used in ADHD cautioned in?

A

Heart conditions This is because they can cause tachycardia (fast heart beat)

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138
Q

Which CNS stimulant is licensed for use in Narcolepsy?

A

Dexamfetamine
Can also use methylphenidate but this is unlicensed use

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139
Q

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?

A

Thaiand Han Chinesepeople of chinese ethnicity are most at risk of genetic polymorphisms of the CYP2D6 enzyme

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140
Q

What kind of drugs should be minimised in patients with cognitive impairment, such as dementia?

A

Antimuscarinicse.g. amitriptyline, paroxetine, solifenacin, antipsychoticsCan result in cognitive impariment

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141
Q

What is first line treatment options for patients with mild to moderate Alzheimer’s?

A

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)

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142
Q

What is first line for patients with severe Alzheimer’s in someone who is not on any medication for the condition?

A

Memantine

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143
Q

If a patient is on an Ach inhibitor for their mild/moderate Alzheimer’s, however their condition gets more severe, what should be done?

A

Consider adding memantine. In this case, it can be initiated in primary care without the advice from a specialist

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144
Q

In patients with moderate Alzheimer’s, what is the risk of stopping Ach inhibitor treatment?

A

Can cause a substantial worsening in cognitive function

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145
Q

What is the MHRA warning regarding prescribing antipsychotics in elderly patients with dementia?

A

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

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146
Q

What is the risk of prescribing antipsychotics in patients with Lewy body/Parkinson’s Disease dementia?

A

Antipsychotic drugs can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions

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147
Q

What patient advice is needed for galantamine?

A

Risk of serious skin reaction including Stevens-Johnson

Stop taking if reaction occurs

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148
Q

What is the MHRA advice surrounding switching between different manufacturers’ products in epilepsy?

A

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

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149
Q

What is antiepileptic hypersensitivity syndrome?

A

Rare but potentially fatal syndrome associated with some antiepileptic drugs
The symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy (enlarged lymph nodes) are most commonly seen.

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150
Q

What is the MHRA advice regarding antiepileptic drugs and psychological side effects?

A

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

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151
Q

True or false:Routine injection of vitamin K at birth minimises the risk of neonatal haemorrhage associated with antiepileptics.

A

TRUE

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152
Q

What is 1st line for newly diagnosed focal seizures?

A

Carbamazepine or Lamotrigine

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153
Q

What is 1st line for tonic-clonic seizures? What would be an alternative if this is unsuitable? What is the problem with this?

A

Sodium valproate or lamotrigine

Carbamazepine is an alternative however may exacerbate myoclonic seizures

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154
Q

What is 1st line for absence seizures?What would be an alternative?

A

Ethosuximide or sodium valproate

Lamtorogine is an alternative

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155
Q

What is 1st line for myoclonic seizures?What would be alternative options?

A

Sodium valproate

Topiramate or levetiracetam

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156
Q

Atonic and clonic seizures are usually seen in which patient group?What is the drug of choice for this?

A

Childhood or associated with cerebral damage or mental retardation - Sodium valproate Lamotrigine can be added

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157
Q

Which benzodiazepines can be used in epilepsy management (not status epilepticus)?

A

Clobazam
Clonazepam

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158
Q

Seizures lasting longer than 5 minutes should be treated with what benzodiazepine?What should you monitor?

A

IV lorazepam - can repeat once after 10 minutes if response fails Monitor for hypotension and respiratory depression

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159
Q

IV diazepam is effective in seizures but carries a high risk of what?

A

Thrombophlebitis

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160
Q

True or false:Diazepam IM or suppositories should be used for status epilepticus

A

False- absorption is too slow

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161
Q

If after initial treatment of IV lorazepam and there is no response after 25 mins, what should be used?

A

Phenytoin/phenobarbital/fosphenytoin
If this does not work- anaesthesia

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162
Q

Do brief febrile convulsions need any treatment?

A

No, may give paracetamol to reduce fever However, if prolonged (>5 mins) or recurrent, treat as epileptic seizure.

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163
Q

Is long term anticonvulsant prophylaxis recommended?

A

Rarely indicated

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164
Q

If an epileptic patient becomes pregnant, what supplement is recommended alongside their pregnancy, especially in the first trimester?

A

Folate supplementation to prevent neural tube defects - folic acid 5mg OD

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165
Q

Pregnant patients who are taking what antiepileptics should have fetal growth monitoring?

A

Topiramate or levetiracetam

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166
Q

What conditions can lamotrigine exacerbate?

A

Parkinson’s Disease
Myoclonic seizures

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167
Q

What is a main side effect of lamotrigine?What are the risk factors of this?

A

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

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168
Q

What is the patient advice surrounding lamotrigine?

A
  • 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.
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169
Q

What vitamin supplementation should you consider if a patient is on carbamazepine?

A

Vitamin D - Especially if immobilised for long periods, or who have inadequate sun exposure/dietary intake of calcium

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170
Q

What are the main side effects to look out for if a patient is on carbamazepine?

A

Blood or skin disorders Antiepileptic hypersensitivity syndrome
Seek medical help if fever, rash, mouth ulcers etc occur
ALSO can cause hepatotoxicity so report signs of dark urine, nausea, vomiting

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171
Q

What is an important side effect to look out for with ethosuximide?

A

Blood disorders (fever, mouth ulcers, or bleeding develops)

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172
Q

What severe side effect is associated with fosphenytoin (used for status epilepticus)?

A

Associated with severe cardiovascular reactions- asystole, ventricular fibrillation. Observe patient for at least 30 minutes after infusion

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173
Q

What is the MHRA advice regarding gabapentin?

A

Risk of severe respiratory depression

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174
Q

What are the serious side effects of lamotrigine?

A

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

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175
Q

What antiepileptic is licensed for migraine prophylaxis?

A

Topiramate

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176
Q

What vitamin supplementation should you consider if a patient is on sodium valproate?

A

Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.

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177
Q

What types of toxicity is associated with sodium valproate?

A

Blood disorders
Hepatic failure
Pancreatitis

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178
Q

What is the safety alert associated with injectable phenytoin?

A

Risk of death and severe harm from error with the prescribing/preparation/administration

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179
Q

What vitamin supplementation should you consider if a patient is on phenytoin?

A

Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.

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180
Q

What are the symptoms of phenytoin toxicity?

A

Nystagmus (involuntary eye movement), diplopia (double vision), slurred speech, ataxia, confusion, and hyperglycaemia

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181
Q

What is nystagmus?

A

Involuntary eye movement

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182
Q

What is diplopia?

A

Double vision

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183
Q

What is the patient advice surrounding phenytoin?

A

Can cause agranulocytosis

Recognise signs of blood or skin disorders- report if mouth ulcer, bruising, bleeding develops

Antiepileptic sensitivity syndrome

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184
Q

What are specific side effects with topiramate? Hint - eyes

A

Acute myopia (short sightedness) with secondary angle-closure glaucoma

Encephalopathic symptoms - sedation, confusion

Patients should report signs of raised intra-ocular pressure

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185
Q

What is primidone used for?

A

Essential tremor
Epilepsy

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186
Q

What are specific side effects of IV phenytoin?

A

Bradycardia Hypotension

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187
Q

What is buspirone used for?

A

Acute anxiety

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188
Q

What is a risk with IV diazepam?

A

Venous thrombophlebitis

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189
Q

What is methylphenidate used for?

A

ADHD

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190
Q

How long should bipolar therapy be for?

A

For at least two years from the last manic episode and up to five years if the patient has risk factors for relapse.

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191
Q

Can lithium lower seizure threshold?

A

Yes

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192
Q

Long term use of lithium has been associated with what?

A

Thyroid disorders
Mild cognitive and memory impairment

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193
Q

What are the signs of lithium toxicity?

A

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

194
Q

When should lithium samples be taken?

A

12 hours post dose

195
Q

How often should serum lithium monitoring take place in the initial and continuous treatment phase?

A

Weekly initially
Weekly after every dose change
3 months thereafter

196
Q

What should you test/measure before starting lithium treatment?

A

Cardiac- ECG - can prolong QT
Renal function
Thyroid function
Blood count - can cause leukocytosis
Body weight - dosing for Priadel is based on weight

197
Q

Once initiated on lithium therapy, how often should you measure BMI, electrolytes, eGFR and thyroid function?

A

Every 6 months

198
Q

What is lithium used for?

A

Treatment and prophylaxis of: Mania, Bipolar disorder, Recurrent depression, Aggressive/self harming behaviour

199
Q

What class of drug is first line in depression?

A

SSRI

200
Q

In patients with a history of unstable angina or recent MI, what is the most appropriate antidepressant?

A

Sertraline

201
Q

Are SSRIs or TCAs more sedating?

A

TCAs are more sedating also have more antimuscarinic and cardiotoxic side effects

202
Q

How often should patients be reviewed at the start of antidepressant treatment?

A

Every 1-2 weeks

203
Q

Antidepressant treatment should be continued for at least how many weeks before you consider switching?How many weeks is this in the elderly?

A

4 weeks
6 weeks in the elderly as they may take longer to respond

204
Q

Following first remission, how long should antidepressant treatment be continued for?How long in the elderly?

A

At least 6 months
12 months in the elderly

205
Q

Patients with recurrent depression should receive maintenance treatment for how long?

A

At least 2 years

206
Q

How long should antidepressant treatment be continued for in generalised anxiety disorder?

A

At least 12 months as risk of relapse is high

207
Q

What electrolyte imbalance is associated with antidepressants?Which class of antidepressant is this the most common in?

A

Low sodium
SSRIs
Hyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.

208
Q

True or false:The use of antidepressants has been linked with suicidal thoughts and behaviour

A

TRUE

209
Q

What are the symptoms of serotonin syndrome?

A

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).

210
Q

If a patient fails to respond to their first line SSRI treatment for depression, what would be the options?

A

Increasing the dose
Switching to a different SSRI or mirtazapine
Other 2nd line options:
Lofepramine (TCA), moclobemide (reversible MAOI), and reboxetine (NRI)

211
Q

Management of acute anxiety involves the use of what drug class options?

A

Benzodiazepine or buspirone

212
Q

For chronic anxiety, what is used?

A

Antidepressant - SSRI
If patient cannot tolerate SSRI, pregabalin can be considered
Benzodiazepine may be needed until the antidepressant starts to work

213
Q

After how many weeks is anxiety classed as chronic?

A

4 weeks

214
Q

Panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder are treated with what drug class?

A

SSRIs

215
Q

What are the less sedating TCAs?

A

Imipramine hydrochloride, lofepramine, and nortriptyline.

216
Q

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?

A

2 weeks 3 weeks if starting clomipramine or imipramine

217
Q

What is the patient advice surrounding MAOIs?

A

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

218
Q

MAOI interactions can persist for how long after discontinuing MAOI?

A

2 weeks

219
Q

Can SSRIs cause QT prolongation?

A

Yes

220
Q

What type of drug is duloxetine?

A

SNRI

221
Q

What type of drug is venlafaxine?

A

SNRI

222
Q

What type of drug is trazadone and what is it used for?

A

Serotonin uptake inhibitor
Depression particularly when sedation is required

223
Q

What are SSRIs cautioned in?

A

Cardiac disease
Bleeding- especially GI
Epilepsy as they can cause seizures

224
Q

Can mirtazapine cause QT prolongation?

A

Yes

225
Q

What is the patient advice regarding mirtazapine?

A

Blood disorders- report fever, sore throat etc

226
Q

Can TCAs cause QT prolongation?

A

Yes

227
Q

Which antidepressant class is associated with a high rate of fatality?

A

TCAs
Cardiovascular and epileptogenic effects
Cautioned in those with a high risk of suicide- consider reduced supply on prescription so there are more regular reviews

228
Q

What class of drug is dosulepin?

A

TCA

229
Q

What are the symptoms of TCA overdose?

A

Hypotension
Hypothermia
Convulsions
Respiratory failure
Dilated pupils
Urinary retention

230
Q

What do you need to consider in terms of the dose in patients on oral antipsychotics that require a change to IM?

A

IM bypasses first pass metabolism so consider a lower dose than that of the oral

231
Q

In schizophrenia, are antipsychotics more effective on the negative or positive symptoms?

A

More effective on the positive symptoms

232
Q

What is dystonia?

A

Abnormal face/body movements

233
Q

Which antipsychotic is least likely to cause hyperprolactinaemia?

A

Ariprazole

234
Q

Which antipsychotics are most likely to cause hyperprolactinaemia?

A

RA
Risperidone, amisulpride, first generation antipsychotics

235
Q

Which antipsychotics carry the highest risk of QT prolongation?

A

Haloperidol Pimozide HP

236
Q

Which antipsychotics commonly cause weight gain?

A

Clozapine
Olanzipine

237
Q

Which antipsychotics commonly cause hyperglycaemia and diabetes?

A

Clozapine Olanzipine
Risperidone Quetiapine
Corq

238
Q

Are first or second generation antipsychotics better at treating negative symptoms of schizophrenia?

A

Second generation

239
Q

If extra-pyramidal side effects are a concern, should first or second generation antipsychotics be prescribed?

A

Second generation

240
Q

Which antipsychotic is least likely to cause QT prolongation?

A

Aripriprazole

241
Q

Are first or second generation antipsychotics more likely to cause insulin resistance and diabetes?

A

Second generation is more likely

242
Q

Which antipsychotics are least likely to cause weight gain?

A

hAA

Ariprazole Haloperidol Amisulpride

243
Q

Patients should receive an antipsychotic for how many weeks before it is deemed ineffective?

A

4-6 weeks

244
Q

When should clozapine be used in schizophrenia?

A

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

245
Q

True or false:Clozapine patients must be registered with a clozapine patient monitoring service

A

TRUE

246
Q

What monitoring is required at the start of antipsychotic treatment?

A

Full blood count, urea and electrolytes, and liver function test monitoring
Blood lipids
Weight Fasting blood glucose and blood pressure
ECG if history of cardiovascular risk factors present

247
Q

What is the MHRA advice regarding clozapine?

A

Potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus
If constipation develops, seek immediate medical advice

248
Q

How does clozapine interact with smoking?

A

Smoking breaks down clozapine so a higher dose may be needed

249
Q

Is haloperidol a first or second generation antipsychotic?

A

First

250
Q

Is olanzapine a first or second generation antipsychotic?

A

Second

251
Q

Is clozapine a first or second generation antipsychotic?

A

Second

252
Q

What is the important safety information associated with dopamine-receptor antagonists e.g. levodopa?

A

Impulse control disorders e.g. gambling, binge eating, hypersexuality

Sudden onset of sleep

253
Q

What is the patient advice regarding co-benelodopa?

A

Sudden onset of sleep
Caution when driving/operating machinery

Impulse control disorders

254
Q

Madopar contains which drug?

A

Co-beneldopa

255
Q

Sinemet contains which drug?

A

Co-careldopa

256
Q

Stalevo contains which drug combination?

A

Levodopa, carbidopa, entacapone

257
Q

What neurological condition is amantadine used in?

A

Parkinson’s Disease

258
Q

What is apomorphine used for? How do you manage the associated nausea and vomiting side effect?

A

Advanced Parkinson’s Disease - “off” episodes
To 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)

259
Q

What is the important safety information regarding bromocriptine and cabergoline?

A

Associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions.Impulse control disorders

260
Q

What would be first line in the following condition:A patient with Parkinson’s whose motor symptoms are decreasing their quality of life

A

Co-carelopda or co-benelopda

261
Q

What would be first line in the following condition:A patient with Parkinson’s whose motor symptoms are NOT affecting their quality of life

A

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).

262
Q

Levodopa is associated with what side effect?

A

Motor complications, including response fluctuations (on and off periods) and dyskinesias
Take at specific times of the day to avoid “off” periods However, the overall motor improvement is more noticeable with levodopa

263
Q

Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered what?

A

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

264
Q

If drug therapy is required for a Parkinson’s Disease patient who develops postural hypotension, what is considered as first line?

A

Midodrine

265
Q

What is an advantage of domperidone over metoclopramide?

A

Less readily crosses the BBB so less likely to cause sedation and dystonic reactions

266
Q

What is aprepitant used for?

A

Nausea and vomiting in chemotherapy

267
Q

If vomiting during the first trimester of pregnancy is severe and requires drug therapy, what is used?

A

Short term antihistamine e.g. promethazine

268
Q

What is Hyperemesis gravidarum?

A

Severe vomiting in pregnancy

269
Q

In Hyperemesis gravidarum what vitamin supplementation should be considered?

A

Thiamine to reduce the risk of Wernicke’s

270
Q

What is the MHRA warning associated with domperidone?

A

Risk of cardiac side effects QT prolongationMax treatment duration should not normally exceed 1 week

271
Q

What is the MHRA warning associated with metoclopramide?

A

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 <18 years

272
Q

Can ondansetron cause QT prolongation?

A

Yes

273
Q

What is the problem with enteric coated aspirin in acute pain?

A

Slow onset of action

274
Q

What are the weak opioids?

A

Codeine
Dihydrocodeine
Meptazinol

275
Q

At what body weight should IV paracetamol be adjusted and what dose should you use?

A

<50kg
15mg/kg

276
Q

What is the MHRA warning regarding codeine?

A

Restricted use in children due to reports of morphine toxicity
Codeine 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

codeine is contra-indicated in:

children younger than 12 years old
patients of any age known to be CYP2D6 ultra-rapid metabolisers
breastfeeding mothers

277
Q

What is a potential side effect of IV fentanyl?

A

Muscle rigidity (may involve thoracic muscles)

278
Q

Why should you monitor patients using fentanyl patches if they have a fever?

A

Increased absorption of drug

279
Q

Why mustn’t you expose fentanyl patches to heat e.g. baths and saunas?

A

May increase absorption

280
Q

True or false:Pethidine has multiple strengths in tablet form

A

False- only has 50mg strength so do not legally need to state the strength on the prescription

281
Q

What is the difference between oxynorm and oxycontin?

A

Oxynorm- immediate release oxycodone
Oxycontin- modified release oxycodone

282
Q

What is the difference between Shortec and Longtec

A

Shortec- immediate release oxycodoneLongtec- modified release oxycodone

283
Q

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.

A

TRUE

284
Q

In what situations would you consider migraine prophylaxis?

A
  • 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
285
Q

What is the most commonly used beta blocker for migraine prophylaxis?

A

Propranolol

286
Q

A self adhesive capsaicin patch 8% is licensed in what?

A

Treatment of peripheral neuropathic pain in non-diabetic patients

287
Q

Capsaicin cream 0.075% is licensed in what?

A

Post herpetic neuralgia
Painful diabetic neuropathy
Osteoarthritis

288
Q

Is withdrawal is more common with the short or long acting benzodiazepines?

A

Short acting

289
Q

Is diazepam short or long acting?

A

Long acting - good for if insomnia is associated with daytime anxiety

290
Q

Is lorazepam short or long acting?

A

Short acting - little or no hangover effect

291
Q

What kind of effect can happen as a result of taking benzodiazepines?

A

Paradoxical effects
A paradoxical increase in hostility and aggression may be reported by patients taking benzodiazepines

292
Q

Why are benzodiazepines cautioned in hepatic impairment?If they are needed, are short or long acting ones recommended?

A

Can precipitate coma
Short acting(However, in alcohol withdrawal, a long acting e.g. chordiazepoxide or diazepam is used via fixed dosed regimen)

293
Q

For patients on opioid maintenance therapy, what should happen if they miss:1) 3 or more days 2) 5 or more days

A

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

294
Q

For opioid addiction, what can be used for opioid maintenance therapy?

A

Buprenorphine or methadone

295
Q

Is buprenorphine or methadone more sedating?

A

Methadone
For 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

296
Q

What is first line for alcohol dependence?What would be an alternative?

A

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

297
Q

What should be given to alcohol dependent patients who are at risk of Wernicke’s encephalopathy?

A

Thiamine

298
Q

What is the patient advice regarding disulfiram?

A

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.

299
Q

What is varenicline used for?

A

Smoking cessationBrand name= Champix

300
Q

What is the MHRA advice regarding varenicline?

A

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.

301
Q

What monitoring does clozapine require?

A

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 service
Blood lipids and weight at baseline
FASTING blood glucose baseline
Baseline prolactin

302
Q

If it does need diluting, IV phenytoin should be administered in what fluid via what and why?

A

Sodium chloride Via large vein, in line phenytoin filter is needed as it precipitates easily

303
Q

When should lithium be stopped before major surgery?

A

24 hours

304
Q

Ethosuximide is used for what type of seizures?

A

Absence Myoclonic

305
Q

Hair loss with regrowth of curly hair is a rare effect of which antileptic drug?

A

Valproate

306
Q

Taking trimethoprim with phenytoin primarily increases the risk of what?

A

Megaloblastic anaemia
Trimethoprim inhibits folate synthesis
Phenytoin increases folate metabolism
(Same with trimethoprim and methotrexate)

307
Q

Purple glove syndrome is a rare side effect of which epilepsy drug?

A

Phenytoin

308
Q

What is the ideal level range for lithium?For acute episodes of mania, what would the target level range be?

A

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

309
Q

What is the risk of abrupt lithium withdrawal?How should it be withdrawn?

A

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).

310
Q

What is the patient advice regarding diet and fluid intake if on lithium therapy?

A

Maintain adequate fluid intake and avoid dietary changes which reduce or increase sodium intake.

311
Q

How does lithium interact with ACEis?

A

Risk of lithium toxicity
Excretion of lithum reduced by ACEi

312
Q

How does lithium interact with NSAIDs?

A

Risk of lithium toxicity
Excretion of lithium probably reduced by NSAIDs

313
Q

How does lithium interact with loop and thiazide diuretics?

A

Excretion of lithium reduced by Loop and Thiazide – Sodium depletion

314
Q

How does lithium interact with amiodarone?

A

Risk of ventricular arrhythmias

315
Q

What is the desired total serum concentration for phenytoin?What can be a disadvantage of measuring total concentration?

A

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

316
Q

Are preparations containing phenytoin sodium and phenytoin base bioequivalent?

A

No

317
Q

Why is it important to maintain good oral hygiene if taking phenytoin?

A

Can cause gingival hyperplasia

318
Q

How does phenytoin interact with NSAIDs?

A

Effect of phenytoin enhanced by NSAIDs

319
Q

How does phenytoin interact with amiodarone?

A

Amiodarone inhibits metabolism of phenytoin

320
Q

How does phenytoin interact with warfarin?

A

Phenytoin accelerates metabolism of warfarin

321
Q

How does phenytoin interact with cimetidine?

A

Cimetidine inhibits the metabolism of phenytoin

322
Q

How does phenytoin interact with fluoxetine?

A

Phenytoin concentration increased by fluoxetine

323
Q

How does phenytoin interact with St John’s Wort?

A

St. Johns Wort (an enzyme inducer) reduces plasma conc. of phenytoin

324
Q

Is lithium use associated with hyper or hypothyroidism?

A

Hypothyroidism

325
Q

Which of these side effects is not associated with lithium?Hyperthyroidism Tremors
increased
urination/thirst
Leukocytosis

A

Hyperthyroidism

Lithium Associated with hypothyroidism

326
Q

Which of these side effects is not associated with phenytoin?

Skin coarsening
Gum hypertrophy
Hair loss
Osteomalacia

A

Hair loss Associated with substantial hair growth (hypertrichosis)

327
Q

Sinemet absorption is reduced when taken with foods high in what nutrient?

A

Protein as it competes with levodopa for absorption

328
Q

Are typical antipsychotics first or second generation antipsychotics?

A

First generation

329
Q

Are atypical antipsychotics first or second generation antipsychotics?

A

Second generation

330
Q

What antibiotic class can result in carbamazepine toxicity?

A

Macrolides

Sodium valproate avoid with penams

331
Q

What antidepressant can be used for smoking cessation?

A

Bupropion

332
Q

Carbamazepine commonly causes what electrolyte imbalance?

A

Hyponatraemia

333
Q

True or false:Phenytoin is not known to cause skin pigmentation

A

False
Causes yellow-brown pigmentation

334
Q

What is the advice surrounding antipsychotics and sunlight?

A

As photosensitisation may occur with higher dosages, patients should avoid direct sunlight.

335
Q

What is the general advice regarding monitoring patients on antipsychotics?

A

ECG may be required before treatment
Monitor 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.

336
Q

What is the advice regarding treatment cessation of antipsychotic drugs?

A

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.

337
Q

What is the NICE 2017 guidance surrounding choice of Donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease?

A

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

338
Q

What is ergotamine used for?In what patient groups would this not be appropriate for?

A

Cluster headaches - unlincensed coronary heart disease; hyperthyroidism; inadequately controlled hypertension; obliterative vascular disease; peripheral vascular disease; Raynaud’s syndrome; sepsis; severe hypertension; temporal arteritis

339
Q

What are the contraindications for benzodiazepines?

A

Acute pulmonary insufficiency; marked neuromuscular respiratory weakness; sleep apnoea syndrome; unstable myasthenia gravis

340
Q

Selegiline is what type of drug?

A

Monoamine oxidase B inhibitor

341
Q

What is used as adjunct to co-beneldopa or co-careldopa to reduce ‘end of dose’ deterioration?

A

Selegiline - can be used alone Enatcapone Tolcapone

342
Q

What parkinsons disease drug colours your urine reddish brown?

A

Entacapone

343
Q

What Parkinson’s Disease medicine can exacerbate oedema and cautioned in congestive heart failure?,

A

Amantadine

344
Q

Hair loss is a common side effect of what Parkinsons Medicine?

A

Selegiline

345
Q

How do you manage status epilepticus?

A
  • 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
346
Q

Treatment with domperidone should not exceed how many days?

A

7 days

347
Q

Treatment with metoclopramide should not exceed how many days?

A

5 days

348
Q

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

A

Inpatient setting is usually 4 weeks Community setting is usually 12 weeks

349
Q

If a patient is on an opioid withdrawal regime but starts to use illicit drugs again, what should happen?

A

The withdrawal regimen should be stopped and maintenance therapy should be resumed at the optimal dose.

350
Q

Following successful opioid withdrawal treatment in the management of addiction, how long should the patient be followed up for?

A

6 months at least

351
Q

True or false:For opioid addiction replacement therapy, buprenorphine has to be given every day

A

False Can be given on alternate days in higher doses

352
Q

Does buprenorphine or methadone require a shorter drug-free period (before naltrexone is needed for relapse prevention)?

A

Buprenorphine

353
Q

Which carries a higher risk of overdose during opioid replacement therapy:Methadone Buprenoprhine

A

Methadone Has more severe withdrawal symptoms

354
Q

Which of the following can you titrate faster:MethadoneBuprenoprhine

A

Buprenoprhine - can titrate within 1 weekMethadone can take several weeks

355
Q

After how many hours of heroin use can you administer:MethadoneBuprenoprhineWhy does there need to be a gap?

A

At least 8 hours after for methadone 6-12 hours after for BuprenoprhineThis is to reduce the risk of precipitated withdrawal

356
Q

What is the recommendation of opioid withdrawal in pregnancy during:i) 1st trimesterii) 2nd trimesteriii) 3rd trimester

A

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

357
Q

What is the only trimester that you can do opioid withdrawal therapy?

A

2nd

358
Q

If a patient on methadone becomes pregnant, should they stop the methadone?

A

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.

359
Q

What do you need to consider in the third trimester in terms of methadone and drug metabolism?

A

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.

360
Q

What is the advice regarding opioid substitution during breastfeeding?What red flag symptoms should you look out for?

A

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

361
Q

What is lofexidine used for?

A

Management of symptoms of opioid withdrawalCan be prescribed as an adjuvant to opioid substitution therapy

362
Q

Smokers who wish to stop smoking should be referred to where?

A

Their local NHS Stop smoking services

363
Q

What are the most effective drug treatments for smoking cessation?

A

VareniclineorCombination of long acting NRT (patch) AND short acting NRT (gum, lozenge etc)

364
Q

How long are nicotine patches generally applied for?In what group of patients would this be longer?

A

16 hours a day, patch removed overnight24 hours a day is the patient experiences strong nicotine cravings upon waking

365
Q

Can varenicline be used alongside NRT?

A

No

366
Q

Can varenicline be used alongside bupropion for smoking cessation?

A

No

367
Q

For smoking cessation, how much treatment should be prescribed for the patient?

A

2 weeks with an assessment just before their supply finishes

368
Q

Can e-cigarettes be supplied by smoking cessation services?

A

No

369
Q

When should NRT be used in smoking pregnant patients?

A

Only if non-drug treatment options have failed

370
Q

What drugs do cigarettes interact with and require higher doses as metabolism is increased?

A

Theophylline
Clozapine
Olanzapine
Haloperidol
Chlorpromazine Ropinerole Cinacalcet

371
Q

What are the side effects of nicotine containing preparations?

A

Local irritation
GI disturbances
Dry mouth if spray, lozenge
Palpitations - rarely with patches
oral spray Hot flushes

372
Q

Abnormal dreams can occur with which NRT preparation?

A

Patch- this is reduced if removed before bed

373
Q

Where should you apply an NRT patch?Do you have to rotate sites of application?

A

Trunk, upper arm, hip
Yes- Avoid using the same site for several days

374
Q

How long before the target smoking quit date should varenicline and bupropion be started?

A

7-14 days before

375
Q

Are e-cigs licensed is smoking cessation?

A

No - aways recommend a licensed treatment if asked e.g. NRT patch

376
Q

A CO level of what suggests the person has stopped smoking or is a non-smoker?

A

10 ppm or less

377
Q

How long after starting varenicline or bupropion should the person be followed up?How does this compare with NRT?

A

3-4 weeks
2 weeks for NRT

378
Q

How many weeks is a course of varenicline?

A

12 weeks

379
Q

Capsaicin 0.025% cream is licensed for what?

A

Symptomatic relief in osteoarthritis

380
Q

Using antipsychotics and what drug for dementia can increase the risk of neuroleptic malignant syndrome?

A

Donepezil

381
Q

What Acetylcholinerase inhibitor is licensed for dementia in Parkinson’s Disease (Lewy body)?

A

Rivastigmine

382
Q

For rivastigmine patches, you should avoid using the same area on the body for how many days?

A

14 days

383
Q

What are the side effects of cholinergic drugs? (DUMB BELS)

A

Diarrhoea
Urination
Muscle weakness/cramps
Bronchospasm
Bradycardia
Emesis
Lacrimation (teary eyes) Salivation/sweating

384
Q

Does lamotrigine have a short or long half life?

A

Long, allows for OD dosing

385
Q

Does phenytoin have a short or long half life?

A

Long, allows for OD dosing

386
Q

Does phenobarbital have a short or long half life?

A

Long, allows for OD dosing

387
Q

Does levetiracetam need to be prescribed by brand?

A

No - Category 3

388
Q

Does lamotrigine need to be prescribed by brand?

A

Based on clinical judgement - Category 2

389
Q

Does valproate need to be prescribed by brand?

A

Based on clinical judgement - Category 2

390
Q

Does ethosuximide need to be prescribed by brand?

A

No- Category 3

391
Q

Does topimarate need to be prescribed by brand?

A

Based on clinical judgement - Category 2

392
Q

With antiepileptic carries the risk of cleft palate following exposure in the first trimester?

A

Topiramate

393
Q

What antiepileptics are present in high amounts in breast milk? (ZELP)

A

Zonisamide
Ethosuximide
Lamotrigine
Primidone

394
Q

What antiepileptics accumulate in breast feeding children due to a slower metabolism?

A

Phenobarbital Lamotrigine

395
Q

What antiepileptics inhibit sucking reflex in breast feeding?

A

Phenobarbital Primidone

396
Q

What antiepileptics have an established risk of drowsiness in babies?

A

Benzodiazepines
Phenobarbital Primidone

397
Q

What antiepileptics carry a high risk of withdrawal symptoms?

A

Phenobarbital Primidone

398
Q

What antiepileptics are mainly associated with antiepileptic hypersensivitiy syndrome?(CP3L)

A

Carbamazepine
Phenytoin
Phenobarbital
Primidone
Lamotrigine In first 8 weeks of starting discontinue immediately

399
Q

What antiepileptics can cause blood dyscrasias?

Zeltcvp

A

Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine
Zonisamide

400
Q

What are the signs of phenytoin toxicity? (SNACHD)

A

Slurred speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia
Diplopia

401
Q

What pre-treatment screening is needed in Chinese and Thai patients when starting phenytoin and carbamazepine- why?

A

HLB-B*1502 allele - have an increased risk of Steven-Johnson syndrome

402
Q

True or false:Phenytoin inhibits Vitamin D metabolism

A

FalseIt induces Vitamin D metabolism- consider supplementation in immobilised patients/inadequate sun exposure or dietary intake of calcium

403
Q

Why is phenytoin cautioned in hepatic impairment?

A

Decreased protein binding so increased risk of toxicity

404
Q

How does phenytoin and levothyroxine interact?

A

Phenytoin= enzyme inducer so reduces drug concentration
Increased risk of hypothyroidism

405
Q

What are the symptoms of carbamazepine toxicity (I HANDBAG)?

A

Incordination
HYPOnatraemia
Ataxia
Nystagmus
Drowsiness
Blurred vision,
diplopia
Arrhythmias
GI disturbances

406
Q

If a whole pack of sodium valproate cannot be dispensed, what must be put on the part pack?

A

Warning sticker

407
Q

If a patient on sodium valproate is experiencing nausea, vomiting, abo pain, what should you do?

A

Refer Could be hepatotoxicity or pancreatitis

408
Q

What groups of patients are short acting benzodiazepines more suitable for?

A

Elderly

409
Q

What is a disadvantage of short acting benzodiazepines?

A

Hepatic impairment (however in acute alcoholic withdrawal a longer benzodiazepine is used)

410
Q

Withdrawal symptoms can occur without how much time of stopping a short acting benzodiazepine?

A

1 day

411
Q

Withdrawal symptoms can occur without how much time of stopping a long acting benzodiazepine?

A

Within 3 weeks

412
Q

How would you reduce someone’s diazepam dose if on long term therapy to prevent withdrawal?If on high doses, how is this done?

A

Reduce diazepam dose, usually by 1–2 mg every 2– 4 weeks
For high doses- reduce by up to one tenth every 1-2 weeks

413
Q

What schedule is methylphenidate (Concerta)?

A

Cd 2

414
Q

What are the side effects of methylphenidate and dexamfetamine?

A

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 disorders
Monitor the above after a dose change and then every 6 months

415
Q

How would you treat an acute episode of mania?

A

Benzodiazepines
Antipsychotics- quetiapine, olanzapine, risperidone
Lithium or valproic acid can be added if inadequate response

416
Q

What can you use for prophylaxis of bipolar disorder?

A

Lithium
Valproate

417
Q

What should you not give in patients with bipolar?

A

Antidepressants

418
Q

What are the signs of lithium toxicity? (REVNG)

A

Renal disturbances
Extrapyramidal symptoms
Visual disturbances
Nervous system disturbances
GI side effects

419
Q

If a patient has persistent headaches and on lithium, what should you do?

A

Refer Lithium can cause benign intracranial hypertension

420
Q

A deficiency in what electrolyte can lead to lithium toxicity?

A

Sodium (hyponatraemia) Therefore, be careful if on drugs that cause low sodium e.g. diuretics

421
Q

What is the only antidepressant licensed in children?

A

Fluoxetine

422
Q

Can SSRIs lower seizure threshold?

A

Yes

423
Q

Can TCAs cause seizures?

A

Yes

424
Q

What is the interaction between TCAs and antihypertensives?

A

Increased risk of hypotension

425
Q

Is moclobemide a reversible or irreversible MAOI?

A

Reversible - no washout period needed as it is short acting

426
Q

With what MAOIs are hepatotoxicty more likely?

A

Phenelzine Isocarboxazid

427
Q

What is the advice surrounding clozapine and missed doses?

A

If 2 or more doses missed, then need to re-titrate dose

428
Q

Sexual dysfunction is most common with what antipsychotics?

A

Haloperidol and risperidone

429
Q

Can antipsychotics interfere with your temperature regulation?

A

Yes

430
Q

Can antipsychotics cause neuroleptic malignant syndrome?

A

Yes

431
Q

What are the advantages of using peripheral dopa-decarboxylase inhibitors for Parkinson’s?

A

Lower dose needed for therapeutic effectFewer side effects - nausea, vomiting, cardiovascular events

432
Q

What are the side effects of ergot derived dopamine agonists rotigotine, pramipexole, ropinerole, cabergoline, bromocriptine, amantadine, apomorphine?

A

Fibrotic reactions Pulmonary- look out for SOB, cough
Retroperitoneal - look out for abdominal pain and tenderness
Pericardial- look out for cardiac failure

433
Q

Is COMT inhibitor monotherapy licensed in Parkinson’s?

A

No Used as an adjunct to levodopa

434
Q

What kind of toxicity is caused by tolcapone?

A

Hepatotoxicty Look out for vomiting, dark urine, abdominal pains

435
Q

What two electrolyte imbalances should be corrected before using 5HT3 antagonists e.g. ondansetron?

A

HYPOkalaemia
HYPOmagnesaemia

436
Q

True or false:Naloxone only partially reverses the effects of buprenorphine

A

TRUE

437
Q

In what situations is it advised for patients to immediately remove a fentanyl patch?

A

Breathing difficulties
Drowsiness, impaired speech
Signs of opioid toxicity

438
Q

Can tramadol lower the seizure threshold?

A

Yes

439
Q

True or false:You can take two doses of sumatriptan for the same attack 2 hours later?

A

True but symptoms must have been improved after taking the first tablet

440
Q

How would you treat trigeminal neuralgia (facial pain with electric shocks in the jaw)?

A

Carbamazepine or phenytoin

441
Q

Transient insomnia is caused by what?

A

Shift work
Jet lag

442
Q

Is zopiclone a long or short acting hypnotic?

A

Short

443
Q

For short term insomnia, hypnotics should not be used for longer than what?

A

3 weeks

444
Q

Can methadone cause QT prolongation?

A

Yes

445
Q

For short term relief of anxiety, hypnotics should not be used for longer than what?

A

2-4 weeks

446
Q

What are the signs of benzodiazepine withdrawal?

A

It is characterised by insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances

447
Q

During benzodiazepine withdrawal, what 3 classes of drugs should be avoided if possible (in the case of additional therapy to help with withdrawal symptoms)?

A

Beta blockers
Antidepressants
Antipsychotics

448
Q

In terms of insomnia, in what cases are short acting hypnotics preferred?

A

Sleep onset insomnia
Where sedation the following day is not desirable
Elderly
Short term insomnia

449
Q

In terms of insomnia, in what cases are long acting hypnotics preferred?

A

Poor sleep maintenance e.g. early morning awakening that causes daytime effects
If an anxiolytic effect is needed during the day
Diazepam

450
Q

How should transient insomnia be managed?

A

Usually self-limiting and short term e.g. jet lag
If a hypnotic is indicated one that is rapidly eliminated should be chosen, and only one or two doses should be given

451
Q

How can chronic insomnia be managed?What are the common causes of chronic insomnia?

A

Rarely benefited by hypnotics and is sometimes due to mild dependence caused by injudicious prescribing of hypnotics
The underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia.Anxiety, depression, and abuse of drugs and alcohol are common causes

452
Q

What is the risk of long term benziodiazepine therapy in the management of insomnia?

A

Can cause rebound insomnia and a withdrawal syndrome.

453
Q

Is withdrawal more common with short or long acting benzodiazepines?

A

Short acting

454
Q

What would be an appropriate benzodiazepine for someone suffering from insomnia with daytime anxiety?

A

Diazepam - long acting
Single dose at night

455
Q

What role do beta blockers play in anxiety?

A

Can help with the autonomic physical symptoms e.g. tremor and palpitations
They do not reduce non-autonomic symptoms, such as muscle tension
They do not help with psychological symptoms

456
Q

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.

A

True

457
Q

What is 1st line for mild depression if a patient is presenting for the first time?

A

Psychological therapy should be considered initially
If history of moderate or severe depression, consider antidepressant therapy

458
Q

What class of drug is mirtazapine/miansirin?

A

TETRAcycline antidepressant

459
Q

Venlafaxine is generally reserved for what type of depression?

A

Severe

460
Q

What is classed as chronic anxiety?

A

> 4 weeks

461
Q

Is generalised anxiety disorder a form of acute or chronic anxiety?

A

Chronic

462
Q

What class of drug is duloxetine?

A

SNRI

463
Q

If changing from fluoxetine to MAOI, what is the period of time you can start this after fluoxetine has been stopped?

A

At least 5 weeks
With other SSRIs, it is only 1 week

464
Q

How long should a patient not drive through after an unprovoked seizure?

A

6 months

465
Q

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?

A

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

466
Q

If an epileptic patient has had a seizure whilst asleep, the patient should not drive for 12 months. What are the exceptions?

A

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

467
Q

If withdrawn from an epilepsy med, how long should a patient not drive for?

A

6 months

468
Q

What is the MHRA warning associated with the sedating antihistamine hydroxyzine?

A

QT prolongation

469
Q

What is the therapeutic range for carbamazepine?

A

4-12 mg/l

470
Q

Has pregabalin got an MHRA warning on the risk of severe respiratory depression?

A

No - Gabapentin does

471
Q

What is amitriptyline used for?

A

Major depressive disorder- not recommended
Migraine prophyaxis
Neuropathic pain

472
Q

What would be the starting dose of amitriptyline for neuropathic pain?

A

10-25mg ON max 75mg

473
Q

What is pregabalin used for in terms of pain?

A

Peripheral AND central neuropathic pain

474
Q

What would be the starting dose of pregabalin for neuropathic pain?

A

150mg daily divided doses

475
Q

What is gabapentin used for in terms of pain?

A

Only peripheral neuropathic pain

476
Q

Examples of antimuscarinic drugs

A

Atropine
Scopolamine
Ipratropium
Tiotropium
Toleterodine
Solifenacin
Benztropine
Trihexyphenidyl

477
Q

Effects of Atropine as antimuscarinic drug

A

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

478
Q

Scopolamine

A

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

479
Q

Antimuscarinics USE

A

Prior to eye operation = atropine
Motion sickness = scopolamine
COPD maintenance of bronchospasms = ipratropium/tiotropium
Bladder problems = Tolterodine / solifenacin/ oxybutynin/ fesoterodine
Parkinson like disorders = Benztropine / Trihexyphenidyl

480
Q

Anticholinergic adverse effects

A

ABCDs
A - agitation
B - blurred vision
C - constipation/ confusion
D - dry mouth
S - stasis of urine and sweating

My Pham Notes (22 decks)

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