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Pre Reg 2024 > Chapter 4: Nervous System > Flashcards

Chapter 4: Nervous System Flashcards

1
Q

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

A

Antimuscarinics
e.g. amitriptyline, paroxetine, solifenacin, antipsychotics

Can result in cognitive impariment

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2
Q

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

A

Monotherapy with one of the following Ach inhibitors:
Donezipil
Rivastigmine
Galantamine

Drug tx should only be initiated under a specialist (however can then be managed in primary care)

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3
Q

What is 1st line for patients with SEVERE Alzheimer’s in someone who is not on any medication for the condition?

A

Memantine

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4
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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5
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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6
Q

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

A

^ 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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7
Q

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

A

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

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8
Q

What patient advice is needed for galantamine?

A

Risk of serious skin reaction including Stevens-Johnson Syndrome
Stop taking if reaction occurs

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9
Q

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

A

Category 1: ENSURE BRAND
Carbamazepine, phenobarbital, phenytoin, primidone.

Category 2: Brand clinical judgement
Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide.

Category 3: Brand unnecessary
Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin.

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10
Q

What is antiepileptic hypersensitivity syndrome?

A

Rare but potentially fatal syndrome

The symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy are most commonly seen.

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11
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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12
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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13
Q

What is 1st line for newly diagnosed focal seizures?

A

Carbamazepine or Lamotrigine

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14
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

Lamotrigine, carbamazepine is an alternative however may exacerbate myoclonic seizures

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15
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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16
Q

What is 1st line for myoclonic seizures?

What would be alternative options?

A

Sodium valproate

Topiramate or levetiracetam

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17
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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18
Q

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

A

Clobazam

Clonazepam

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19
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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20
Q

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

A

Thrombophlebitis

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21
Q

True or false:

Diazepam IM or suppositories should be used for status epilepticus

A

False- absorption is too slow

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22
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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23
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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24
Q

Is long term anticonvulsant prophylaxis recommended?

A

Rarely indicated

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25
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

High dose 5mg OD

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26
Q

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

A

Topiramate or levetiracetam

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27
Q

What conditions can lamotrigine exacerbate?

A

Parkinson’s Disease

Myoclonic seizures

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28
Q

What is a main side effect of lamotrigine?

What are the risk factors of this?

A

Hypersensitivity syndrome.
Serious skin rxns: SJS, TEN have developed (ESP in children); most rashes occur in first 8 weeks.
Risk factors include concomitant use of valproate, too high dose or too rapid dose increase

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29
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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30
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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31
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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32
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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33
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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34
Q

What is the MHRA advice regarding gabapentin?

A

Risk of severe respiratory depression

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35
Q

What are the serious side effects of lamotrigine?

A

Skin rxns: within 1-8 weeks. They include serious skin reactions i.e. SJS TEN
Blood disorders - signs such as anaemia, bruising, or infection

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36
Q

What antiepileptic is licensed for migraine prophylaxis?

A

Topiramate

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37
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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38
Q

What types of toxicity is associated with sodium valproate?

A

Blood disorders
Hepatic failure
Pancreatitis

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39
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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40
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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41
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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42
Q

What is nystagmus?

What is diplopia?

A

Involuntary eye movement = nystagmus

Diplopia = Double vision

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43
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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44
Q

What are specific side effects with topiramate? Hint - eyes

A 
Acute myopia (near sightedness) with secondary angle-closure glaucoma
Encephalopathic symptoms - sedation, confusion

Patients should report signs of raised intra-ocular pressure

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45
Q

What is primidone used for?

A

Essential tremor

Epilepsy

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46
Q

What are specific side effects of IV phenytoin?

A

Bradycardia

Hypotension

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47
Q

What is buspirone used for?

A

Acute anxiety

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48
Q

What is a risk with IV diazepam?

A

Venous thrombophlebitis

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49
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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50
Q

Can lithium lower seizure threshold?

A

Yes

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51
Q

Long term use of lithium has been associated with what?

A

Thyroid disorders

Mild cognitive and memory impairment

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52
Q

What are the signs of lithium toxicity?

A 
GI disturbances- n+v, diarrhoea 
Visual disturbances, nystagmus
Tremor. Restlessness.
CNS - confusion, drowsy, lack of coordination 
Hypernatraemia 
Cardiac arrhythmias. Circulatory failure
Renal failure
Increased thirst. Polyuria.
Memory impairment. Coma
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53
Q

When should lithium samples be taken?

A

12 hours post dose

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54
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

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55
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
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56
Q

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

A

Every 6 months

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57
Q

What is lithium used for?

A 
Treatment and prophylaxis of:
Mania
Bipolar disorder
Recurrent depression
Aggressive/self harming behaviour
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58
Q

What class of drug is first line in depression?

A

SSRI

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59
Q

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

A

Sertraline

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60
Q

Are SSRIs or TCAs more sedating?

A

TCAs are more sedating

Also have more antimuscarinic and cardiotoxic side effects

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61
Q

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

A

Every 1-2 weeks

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62
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

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63
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

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64
Q

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

A

At least 2 years

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65
Q

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

A

At least 12 months as risk of relapse is high

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66
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.

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67
Q

True or false:

The use of antidepressants has been linked with suicidal thoughts and behaviour

A

True

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68
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).

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69
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)

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70
Q

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

A

Benzodiazepine or buspirone

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71
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

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72
Q

After how many weeks is anxiety classed as chronic?

A

4 weeks

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73
Q

Panic disorder, OCD, PTSD and phobic states such as social anxiety disorder are treated with what drug class?

A

SSRIs

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74
Q

What are the less sedating TCAs?

A

Imipramine hydrochloride, lofepramine, and nortriptyline.

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75
Q

If a pt 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 (TCAs)

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76
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

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77
Q

MAOI interactions can persist for how long after discontinuing MAOI?

A

2 weeks

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78
Q

Can SSRIs cause QT prolongation?

A

Yes

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79
Q

What type of drug is duloxetine?

What type of drug is venlafaxine?

A

SNRI

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80
Q

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

A

Serotonin uptake inhibitor

Depression particularly when sedation is required

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81
Q

What are SSRIs cautioned in?

A

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

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82
Q

Can mirtazapine cause QT prolongation?

Can TCAs cause QT prolongation?

A

Yes

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83
Q

What is the patient advice regarding mirtazapine?

A

Blood disorders- report fever, sore throat etc

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84
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

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85
Q

What class of drug is dosulepin?

A

TCA

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86
Q

What are the symptoms of TCA overdose?

A 
Hypotension
Hypothermia
Convulsions
Respiratory failure
Dilated pupils
Urinary retention
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87
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

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88
Q

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

A

More effective on the positive symptoms

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89
Q

What are the main side effects of antipsychotics?

A
  • Extrapyramidal - parkinsonism, dystonia, tardive dyskinesia
  • Hyperprolactinaemia
  • Sexual dysfunction
  • CVS: QT prolong., hypotension, arrhythmias
  • Hyperglycaemia, DB, weight gain
  • Hypo/hyperthermia
  • Neuroleptic malignant syndrome
  • Blood dyscrasias
  • Photosensitisation
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90
Q

What is dystonia?

A

Abnormal face/body movements

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91
Q

Which antipsychotic is least likely to cause hyperprolactinaemia?

A

Aripiprazole

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92
Q

Which antipsychotics are most likely to cause hyperprolactinaemia?

A

Risperidone, amisulpride, first generation antipsychotics

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93
Q

Which antipsychotics carry the highest risk of QT prolongation?

A

Haloperidol

Pimozide

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94
Q

Which antipsychotics commonly cause weight gain?

A

Clozapine

Olanzipine

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95
Q

Which antipsychotics commonly cause hyperglycaemia and diabetes?

A

Clozapine
Olanzipine
Risperidone
Quetiapine

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96
Q

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

A

Second generation

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97
Q

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

A

Second generation

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98
Q

Which antipsychotic is least likely to cause QT prolongation?

A

Aripriprazole

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99
Q

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

A

Second generation is more likely

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100
Q

Which antipsychotics are least likely to cause weight gain?

A

Aripiprazole
Haloperidol
Amisulpride

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101
Q

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

A

4-6 weeks

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102
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

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103
Q

True or false:

Clozapine patients must be registered with a clozapine patient monitoring service

A

True

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104
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

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105
Q

What is the MHRA advice regarding clozapine?

A

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

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106
Q

What are the specific side effects with clozapine?

A
  • Agranulocytosis
  • Cardiomyopathy
  • Intestinal obstruction
  • Hypersalivation
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107
Q

How does clozapine interact with smoking?

A

Smoking breaks down clozapine so a higher dose may be needed

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108
Q

Is haloperidol a first or second generation antipsychotic?

A

First

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109
Q

Is olanzapine a first or second generation antipsychotic?

A

Second

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110
Q

Is clozapine a first or second generation antipsychotic?

A

Second

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111
Q

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

A

Impulse control disorders e.g. gambling, binge eating

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112
Q

What is the patient advice regarding co-benelodopa?

A

Sudden onset of sleep

Caution when driving/operating machinery

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113
Q

Madopar contains which drug?

A

Co-beneldopa

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114
Q

Sinemet contains which drug?

A

Co-careldopa

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115
Q

Stalevo contains which drug combination?

A

Levodopa, carbidopa, entacapone

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116
Q

What neurological condition is amantadine used in?

A

Parkinson’s Disease

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117
Q

What is apomorphine used for?

How do you manage the associated nausea and vomiting side effect?

A

Advanced Parkinson’s Disease - “off” episodes (loevodopa stops working)

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)

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118
Q

What is the important safety information regarding bromocriptine and cabergoline?

A

Associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions.

Impulse control disorders

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119
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

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120
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).

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121
Q

Levodopa is associated with what side effect?

A

Motor complications, incl. response fluctuations (on / 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

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122
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 levodopa

If these do not work, then bromocriptine/cabergoline/pergolide could be considered

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123
Q

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

A

Midodrine

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124
Q

What is an advantage of domperidone over metoclopramide?

A

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

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125
Q

What is aprepitant used for?

A

Nausea and vomiting in chemotherapy

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126
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

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127
Q

What is Hyperemesis gravidarum?

A

Severe vomiting in pregnancy

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128
Q

In Hyperemesis gravidarum what vitamin supplementation should be considered?

A

Thiamine to reduce the risk of Wernicke’s

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129
Q

What is the MHRA warning associated with domperidone?

A

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

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130
Q

What is the MHRA warning associated with metoclopramide?

A

Risk of neurological side effects
Extrapyramidal disorders and tardive dyskinesia
Recommended that it should only be prescribed for up to 5 days

Especially in young adults <20 years

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131
Q

Can ondansetron cause QT prolongation?

A

Yes

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132
Q

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

A

Slow onset of action

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133
Q

What are the weak opioids?

A

Codeine
Dihydrocodeine
Meptazinol

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134
Q

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

A

<50kg

15mg/kg

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135
Q

What are the side effects of opioid analgesics?

A
  • Constipation
  • Nausea
  • Respiratory depression
  • Drowsiness
  • Dependence and withdrawal
  • Overdose - pinpoint pupils, coma
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136
Q

What is the MHRA warning regarding codeine?

A

Restricted use in children due to reports of morphine toxicity.
Codeine = only used to relieve acute moderate pain in children > 12 yrs only if it cannot be relieved by other painkillers.
Serious life-threatening ADR in children with obstructive sleep apnoea who received codeine after tonsillectomy or adenoidectomy

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137
Q

What is a potential side effect of IV fentanyl?

A

Muscle rigidity (may involve thoracic muscles)

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138
Q

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

A

Increased absorption of drug

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139
Q

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

A

May increase absorption

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140
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

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141
Q

What is the difference between oxynorm and oxycontin?

A

Oxynorm- immediate release oxycodone

Oxycontin- modified release oxycodone

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142
Q

What is the difference between Shortec and Longtec

A

Shortec- immediate release oxycodone

Longtec- modified release oxycodone

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143
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

144
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
145
Q

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

A

Propranolol

146
Q

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

A

Treatment of peripheral neuropathic pain in non-diabetic patients

147
Q

Capsaicin cream 0.075% is licensed in what?

A

Post herpetic neuralgia
Painful diabetic neuropathy
Osteoarthritis

148
Q

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

A

Short acting

149
Q

Is diazepam short or long acting?

A

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

150
Q

Is lorazepam short or long acting?

A

Short acting - little or no hangover effect

151
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

152
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)

153
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 dose
2) An assessment of illicit drug use is also recommended before restarting substitution therapy

154
Q

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

A

Buprenorphine or methadone

155
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

156
Q

What is first line for alcohol dependence?

What would be an alternative?

A

Acamprosate / naltrexone with a psychological intervention

Alternative- disulfiram if the others are not suitable or if the patient wants this but understands the associated risks

157
Q

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

A

Thiamine

158
Q

What is the patient advice regarding disulfiram?

A

Counselled on the disulfiram-alcohol reaction—rxns 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— discontinue tx and seek immediate medical attention if they feel unwell or symptoms such as fever or jaundice develop.

159
Q

What is varenicline used for?

A

Smoking cessation

Brand name= Champix

160
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.

161
Q

What monitoring does clozapine require?

A

Monitor leucocyte and differential blood counts. Clozapine requires differential WBC monitoring weekly for 18 weeks, then fortnightly for up to 1 year, and then monthly
Blood lipids and weight at baseline
FASTING blood glucose baseline
Baseline prolactin

162
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

163
Q

When should lithium be stopped before major surgery?

A

24 hours

164
Q

Ethosuximide is used for what type of seizures?

A

Absence

Myoclonic

165
Q

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

Valproate
Phenytoin
Carbamazepine
Lamotrigine

A

Valproate

166
Q

Taking trimethoprim with phenytoin primarily increases the risk of what?

Hyperkalaemia
Megaloblastic anaemia
Bleeding
Low sodium

A

Megaloblastic anaemia

Trimethoprim inhibits folate synthesis

Phenytoin increases folate metabolism

(Same with trimethoprim and methotrexate)

167
Q

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

A

Phenytoin

168
Q

What is the ideal level range for lithium?

For acute episodes of mania, what would the target level range be?

A
  1. 4–1 mmol/litre -lower end for elderly and for maintenance therapy
  2. 8–1 mmol/litre is recommended for acute episodes of mania
169
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 of up to 3 months).

170
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.

171
Q

How does lithium interact with ACEis?

A

Risk of lithium toxicity

Excretion of lithum reduced by ACEi

172
Q

How does lithium interact with NSAIDs?

A

Risk of lithium toxicity

Excretion of lithium probably reduced by NSAIDs

173
Q

How does lithium interact with loop and thiazide diuretics?

A

Excretion of lithium reduced by Loop and Thiazide – Sodium depletion

174
Q

How does lithium interact with amiodarone?

A

Risk of ventricular arrhythmias

175
Q

What is the desired total serum concentration for phenytoin?

What can be a disadvantage of measuring total concentration?

A

10-20mg/L

However, 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

176
Q

Are preparations containing phenytoin sodium and phenytoin base bioequivalent?

A

No

177
Q

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

A

Can cause gingival hyperplasia

178
Q

How does phenytoin interact with NSAIDs?

A

Effect of phenytoin enhanced by NSAIDs

179
Q

How does phenytoin interact with amiodarone?

A

Amiodarone inhibits metabolism of phenytoin

180
Q

How does phenytoin interact with warfarin?

A

Phenytoin accelerates metabolism of warfarin

181
Q

How does phenytoin interact with cimetidine?

A

Cimetidine inhibits the metabolism of phenytoin

182
Q

How does phenytoin interact with fluoxetine?

A

Phenytoin concentration increased by fluoxetine

183
Q

How does phenytoin interact with St John’s Wort?

A

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

184
Q

Is lithium use associated with hyper or hypothyroidism?

A

Hypothyroidism

185
Q 
Which of these side effects is not associated with lithium?
Hyperthyroidism
Tremors
Increased urination/thirst
Leukocytosis
A

Hyperthyroidism

Associated with hypothyroidism

186
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)

187
Q

Has diazepam got a short or long half life?

A

Long half life

188
Q

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

Protein
Fat
Carbohydrates

A

Protein as it competes with levodopa for absorption

189
Q

Are typical antipsychotics first or second generation antipsychotics?

A

First generation

190
Q

Are atypical antipsychotics first or second generation antipsychotics?

A

Second generation

191
Q

What antibiotic class can result in carbamazepine toxicity?

A

Macrolides

192
Q

What antidepressant can be used for smoking cessation?

A

Bupropion

193
Q

Carbamazepine commonly causes what electrolyte imbalance?

A

Hyponatraemia

194
Q

True or false:

Phenytoin is not known to cause skin pigmentation

A

False

Causes yellow-brown pigmentation

195
Q

What is the advice surrounding antipsychotics and sunlight?

A

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

196
Q

What is the general advice regarding monitoring patients on antipsychotics?

A

ECG may be required before tx
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.

197
Q

What is the advice regarding treatment cessation of antipsychotic drugs?

A

^risk of relapse if medication is stopped after 1–2 years. Withdrawal after long-term therapy should always be gradual and closely monitored. Patients should be monitored for 2 years after withdrawal of antipsychotic medication for signs and symptoms of relapse.

198
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 disease

Tx 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

199
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

200
Q

What are the contraindications for benzodiazepines?

A

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

201
Q

Selegiline is what type of drug?

A

Monoamine oxidase B inhibitor

202
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

203
Q

What parkinsons disease drug colours your urine reddish brown?

A

Entacapone

204
Q

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

A

Amantadine

205
Q

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

A

Selegiline

206
Q

How do you manage status epilepticus?

A
  • IV lorazepam if seizure > 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
207
Q

Treatment with domperidone should not exceed how many days?

Treatment with metoclopramide should not exceed how many days?

A

7 days - Domperidone

5 days - Metoclopramide

208
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 setting
ii) community setting

A

Inpatient setting is usually 4 weeks

Community setting is usually 12 weeks

209
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.

210
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

211
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

212
Q

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

A

Buprenorphine

213
Q

Which of the following can you titrate faster:

Methadone
Buprenoprhine

A

Buprenoprhine - can titrate within 1 week

Methadone can take several weeks

214
Q

After how many hours of heroin use can you administer:

Methadone
Buprenoprhine

Why does there need to be a gap?

A

At least 8 hours after for methadone

6-12 hours after for Buprenoprhine

This is to reduce the risk of precipitated withdrawal

215
Q

What is the recommendation of opioid withdrawal in pregnancy during:

i) 1st trimester
ii) 2nd trimester
iii) 3rd trimester

A

1st trimester- avoid as increased risk of spontaneous miscarriage

2nd 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

216
Q

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

A

2nd

217
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.

218
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 3rd trimester; it may be necessary to either ^ dose of methadone or change to BD consumption (or a comb of both strategies) to prevent withdrawal symptoms from developing.

219
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

220
Q

What is lofexidine used for?

A

Management of symptoms of opioid withdrawal

Can be prescribed as an adjuvant to opioid substitution therapy

221
Q

What are the most effective drug treatments for smoking cessation?

A

Varenicline

or

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

222
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 overnight

24 hours a day is the patient experiences strong nicotine cravings upon waking

223
Q

Can varenicline be used alongside NRT?

A

No

224
Q

Can varenicline be used alongside bupropion for smoking cessation?

A

No

225
Q

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

A

2 weeks with an assessment just before their supply finishes

226
Q

Can e-cigarettes be supplied by smoking cessation services?

A

No

227
Q

When should NRT be used in smoking pregnant patients?

A

Only if non-drug treatment options have failed

228
Q

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

A 
Theophylline
Clozapine
Olanzapine
Haloperidol
Chlorpromazine 
Ropinerole 
Cinacalcet
229
Q

What are the side effects of nicotine containing preparations?

A 
Local irritation 
GI disturbances 
Dry mouth if spray, lozenge
Palpitations - rarely with patches and oral spray 
Hot flushes
230
Q

Abnormal dreams can occur with which NRT preparation?

A

Patch- this is reduced if removed before bed

231
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

232
Q

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

A

7-14 days before

233
Q

Are e-cigs licensed is smoking cessation?

A

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

234
Q

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

A

10 ppm or less

235
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

236
Q

How many weeks is a course of varenicline?

A

12 weeks

237
Q

Capsaicin 0.025% cream is licensed for what?

A

Symptomatic relief in osteoarthritis

238
Q

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

A

Donepezil

239
Q

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

A

Rivastigmine

240
Q

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

A

14 days

241
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

242
Q

Does the following have a short or long half life?
Lamotrigine
Phenytoin
Phenobarbital

A

Long, allows for OD dosing

243
Q

Does levetiracetam need to be prescribed by brand?

A

No - Category 3

244
Q

Does lamotrigine need to be prescribed by brand?

A

Based on clinical judgement - Category 2

245
Q

Does valproate need to be prescribed by brand?

A

Based on clinical judgement - Category 2

246
Q

Does ethosuximide need to be prescribed by brand?

A

No- Category 3

247
Q

Does topimarate need to be prescribed by brand?

A

Based on clinical judgement - Category 2

248
Q

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

A

Topiramate

249
Q

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

A

Zonisamide
Ethosuximide
Lamotrigine
Primidone

250
Q

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

A

Phenobarbital

Lamotrigine

251
Q

What antiepileptics inhibit sucking reflex in breast feeding?

A

Phenobarbital

Primidone

252
Q

What antiepileptics have an established risk of drowsiness in babies?

A

Benzodiazepines
Phenobarbital
Primidone

253
Q

What antiepileptics carry a high risk of withdrawal symptoms?

A

Phenobarbital

Primidone

254
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

255
Q

What antiepileptics can cause blood dyscrasias?

A 
Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine
Zonisamide
256
Q

What are the signs of phenytoin toxicity? (SNACHD)

A 
Slurred speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia
Diplopia
257
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

258
Q

True or false:

Phenytoin inhibits Vitamin D metabolism

A

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

259
Q

Why is phenytoin cautioned in hepatic impairment?

A

Decreased protein binding so increased risk of toxicity

260
Q

How does phenytoin and levothyroxine interact?

A

Phenytoin= enzyme inducer so reduces drug concentration

Increased risk of hypothyroidism

261
Q

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

A

In co-cordination

Hyponatraemia
Ataxia (drunk)
Nystagmus
Drowsiness
Blurred vision, diplopia
Arrhythmias
GI disturbances
262
Q

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

A

Warning sticker

263
Q

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

A

Refer

Could be hepatotoxicity or pancreatitis

264
Q

Is lorazepam short or long acting?

A

Short acting

265
Q

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

A 
Elderly
Hepatic impairment (however in acute alcoholic withdrawal a longer benzodiazepine is used)
266
Q

What is a disadvantage of short acting benzodiazepines?

A

Carries greater risk of withdrawal symptoms

267
Q

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

A

Within 1 day

268
Q

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

A

Within 3 weeks

269
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

270
Q

What schedule is methylphenidate (Concerta)?

A

CD2

271
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

272
Q

What is dexamfetamine used for?

A

Narcolepsy

Refractory ADHD

273
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

274
Q

What can you use for prophylaxis of bipolar disorder?

A

Lithium salts
Sodium valproate / valproic acid
Olanzapine

275
Q

What should you not give in patients with bipolar?

A

Antidepressants

276
Q

What are the signs of lithium toxicity? (REVNG)

A 
Renal disturbances
Extrapyramidal symptoms
Visual disturbances
Nervous system disturbances
GI side effects
277
Q

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

A

Refer

Lithium can cause benign intracranial hypertension

278
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

279
Q

What is the only antidepressant licensed in children?

A

Fluoxetine

280
Q

Can SSRIs lower seizure threshold?

A

Yes

281
Q

Can TCAs cause seizures?

A

Yes

282
Q

What is the interaction between TCAs and antihypertensives?

A

Increased risk of hypotension

283
Q

Is moclobemide a reversible or irreversible MAOI?

A

Reversible - no washout period needed as it is short acting

284
Q

With what MAOIs are hepatotoxicty more likely?

A

Phenelzine

Isocarboxazid

285
Q

What is the advice surrounding clozapine and missed doses?

A

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

286
Q

Sexual dysfunction is most common with what antipsychotics?

A

Haloperidol and risperidone

287
Q

Can antipsychotics interfere with your temperature regulation?
Can antipsychotics cause neuroleptic malignant syndrome?

A

Yes

288
Q

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

A

Lower dose needed for therapeutic effect

Fewer side effects - nausea, vomiting, cardiovascular events

289
Q 
What class of drug is pramipexole?
What class of drug is ropinerole?
What class of drug is rotigotine?
A

Non ergot derived dopamine agonist

290
Q

What are the side effects of ergot derived dopamine agonists?

A

Fibrotic reactions

Pulmonary- look out for SOB, cough

Retroperitoneal - look out for abdominal pain and tenderness

Pericardial- look out for cardiac failure

291
Q

Is COMT inhibitor monotherapy licensed in Parkinson’s?

A

No

Used as an adjunct to levodopa

292
Q

What kind of toxicity is caused by tolcapone?

A

Hepatotoxicty

Look out for vomiting, dark urine, abdominal pain

293
Q

What is the antisickness choice of drug in Parkinson’s?

A

Domperidone

294
Q

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

A

Hypokalaemia and hypomagnesaemia

295
Q

True or false:

Naloxone only partially reverses the effects of buprenorphine

A

True

296
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

297
Q

Can tramadol lower the seizure threshold?

A

Yes

298
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

299
Q

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

A

Carbamazepine or phenytoin

300
Q

Transient insomnia is caused by what?

A

Shift work

Jet lag

301
Q

Is zopiclone a long or short acting hypnotic?

A

Short acting

302
Q

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

A

3 weeks max

Ideally 1 week

303
Q

Can methadone cause QT prolongation?

A

Yes

304
Q

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

A

2-4 weeks

305
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

306
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

307
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

308
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

309
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

310
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

311
Q

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

A

Can cause rebound insomnia and a withdrawal syndrome.

312
Q

Is withdrawal more common with short or long acting benzodiazepines?

A

Short acting

313
Q

Is temazepam long or short acting?

A

Short acting

314
Q

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

A

Diazepam - long acting

Single dose at night

315
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

316
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

317
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

318
Q

What class of drug is mirtazapine?

A

TETRAcycline antidepressant

319
Q

Venlafaxine is generally reserved for what type of depression?

A

More severe

320
Q

What is classed as chronic anxiety?

A

> 4 weeks duration

321
Q

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

A

Chronic

322
Q

What class of drug is duloxetine?

A

SNRI

323
Q

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?

A

At least 5 weeks

With other SSRIs, it is only 1 week

324
Q

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

A

6 months

325
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
326
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
327
Q

Should an epileptic person drive during medication changes?

A

No

328
Q

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

A

6 months

329
Q

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

A

QT prolongation

330
Q

What is the therapeutic range for carbamazepine?

A

4-12 mg/L

331
Q

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

A

No - Gabapentin does

332
Q

What is amitriptyline used for?

A

Major depressive disorder- not recommended
Migraine prophyaxis
Neuropathic pain

333
Q

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

A

10-25mg ON

Max of 75mg

334
Q

What is pregabalin used for in terms of pain?

A

Peripheral AND central neuropathic pain

335
Q

What is the max dose of pregabalin a day?

A

600mg

336
Q

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

A

150mg daily in divided doses

337
Q

What is the max dose of gabapentin a day?

A

3.6g

338
Q

What is gabapentin used for in terms of pain?

A

Only peripheral neuropathic pain

339
Q

What would be the dosing regimen of gabapentin in neuropathic pain?

A

Day 1 - 300mg OD
Day 2 - 300mg BD
Day 3 -300mg TDS

340
Q

Examples of antimuscarinic drugs

A 
Atropine
Scopolamine
Ipratropium
Tiotropium
Toleterodine 
Solifenacin
Benztropine
Trihexyphenidyl
341
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 emptying
Heart - blocks M2 receptors on SA/AV => tachycardia (^30-40bpm)
Salivary/sweat/lacrimal glands = dry mouth, dry skin and ultimately increase in body temperature

342
Q

3 types oc holinergic antagonists

A

1 antimuscarinics
2 Ganglionic blockers
3 Neuromuscular blockers

343
Q

Scopolamine

A

unlike atropine has greater CNS effect and longer duration of action

  • prevent motion sickness
  • post op n+v

patch formulation effect lasting up to 3 days

344
Q

Ipratropium and Tiotropium
MOA
Indication
Difference?

A

Block muscarinic Acetylcholine receptors without specificity for subtypes

M3 block results in decreased contractility of smooth muscle in lungs = bronchodilation =& reduction of mucus secretion

Both administered as inhalation treatment for maintenance bronchospasms for pt in COPD

Ipratropium <= nasal spray = rhinorrea = runny nose

Tiotropium long acting agent dosed once daily
Ipratropium short acting dosed up to qds

tiotropium bromide is electrically charged, not absorbed by the GI tract and does not pass the BBB

345
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

346
Q

Antimuscarinics for bladder conditions

A

Tolterodine
Solifenacin
Oxybutynin
Fesoterodine

M3 receptor. overall efficacy similar.

347
Q

Trihexyphenydil

A

Trihexyphenidyl exerts its effects by reducing the effects of the relative central cholinergic excess that occurs as a result of dopamine deficiency.

348
Q

Anticholinergic adverse effects

A 
ABCDs
A - agitation
B - blurred vision
C - constipation/ confusion
D - dry mouth
S - stasis of urine and sweating
349
Q

Ganglionic blockers’ main agent?

A

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.

350
Q

Neurotransmitters and effects

on Mood and Cognitive function

A

NE - alertness, concentration, energy
==> ATTENTION
Dopamine - pleasure, reward, motivation/drive
==> APPETITE + SEX + AGGRESSION
Serotonin - obsessions, compulsions, memory
==> ANXIETY + IMPULSE + IRRITABILITY
NE

351
Q

SE of NICOTINE

Apart from smoking cessation nicotine is not very useful in clinical practice

A

CNS stimulation ^doses => convulsions
depresses CNS => respiratory paralysis

stimulating adrenal medulla and sympathtic ganglia => ^BP and HR but higher doses can cause BP to fall

GI system: increases motility => nausea and vomiting

Use of nicotine in any form can cause addiction due to CNS stimulation but also alertness and feeling of wellbeing

352
Q

Neuromuscular blockers MOA

A

Block cholinergic transmission between motor nerve endings and nicotinic receptors on the skeletal muscle

Action Potential (AP) => release Acetylcholine at axon of motor neuron
Acetylcholine binds to Nicotinic receptors => opens Na ion channels letting Na ions enter muscle fibre
AP along sarcoplasmic reticulum =>  Ca release => leading to muscle contraction.
353
Q

What are non depolarizing neuromuscular blockers? Clinical uses?

A

Non-depolarizing: competitive antagonists, bind to Acetylcholine receptors but do not induce ion channel (Na) opening. Prevent depolarization of the muscle cell membrane.
Clinical practice: aid mechanical ventilation and tracheal intubation, muscle relaxation during surgery allowing for lower doses of general anaesthetics. Cannot be absorbed from GI and must usually be injected IV onset 2 min. Paralyze small fast contracting muscles first e.g. eyes, fingers, then larger muscles of neck and limbs (recover in reverse)
Cisatracurium, Pancuronium, Atracurium

354
Q

What are depolarizing neuromuscular blockers? Clinical uses?

A

Acetylcholine receptor agonists
Resistant to degradation by acetylcholinesterase => persistent depolarization
succinylcholine binds to nic. rec. => Na channel to open and stay open. Prolonged depolarization => transicent fasciculations => flaccid paralysis ‘Phase 1 block’
Eventually channels close and membrane repolarizes but continued stimulation causes receptor to desensitize to acetylcholine = preventing formation of further action potentials ‘Phase 2 block’

RAPID ONSET (1min lasting 10min) used to facilitate rapid sequence endotracheal intubation in critically ill patients. Muscle relaxation in electroconvulsive therapy.

SE: apnea, hyperkalaemia, systole, malignant hypothermia

355
Q 
Least likely to cause dry mouth (xerostomia)
A. amitriptyline
B. clozapine
C. oxybutynin
D. procyclidine
A

A. amitriptyline - SSRI
B. clozapine - atypical antipsychotic
C. oxybutynin - anticholinergic/antimuscarinic
D. procyclidine - anticholinergic
All can cause anticholinergic SE but clozapine can cause hypersalivation

Pre Reg 2024 (33 decks)

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