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British National Formulary > Chapter 4- Nervous System > Flashcards

Chapter 4- Nervous System Flashcards

1
Q

Name three anticholinesterase inhibitors used in dementia

A

Donepezil Rivastigmine Galantamine

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2
Q

Name the Glutamate receptor antagonist used in more severe dementia

A

Memantine

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3
Q

Name 4 antiepileptics that have long half lives and can be given once daily at bedtime

A

Lamotrigine Perampanel Phenobarbital Phenytoin

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4
Q

Name 4 antiepileptics in category 1 that are prescribed by brand

A

Phenytoin Carbamazepine Phenobarbital Primidone

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5
Q

Drugs that can cause Anti-epileptic syndrome?

A

Carbamazepine

Lacosamide

Lamotrignie

Oxcarbazepine

Phenobarbital

Primodine

Phenyltoin

Rufinamide

(Capsules lack lands once pharmacists poke physical reasons)

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6
Q

When can antiepileptic hypersensitivity syndrome start showing symptoms

A

Between 1 and 8 weeks of exposure

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7
Q

Symptoms of antiepileptic hypersensitivity syndrome

A

Fever

Rash

Lymphadenopathy

Liver, Haematological and Renal Pulmonary abnormalities

Vasculitis

Multi-organ failure

Frigid Raunchy Little Hampsters Redo Private Antisocial Verant Millions

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8
Q

Is there a risk of suicidal thoughts and behaviours with all antiepileptic drugs

A

Yes

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9
Q

What interactions occur with antiepileptics

A

Usually as a result of enzyme induction or inhibition

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10
Q

How do we withdraw antiepileptics?

A

All Antiepilepcitcs are withdrawn gradually and under supervision. Avoid Abrupt withdrawal particularly in barbituates and benzodiazepines as this can cause severe rebound seizures

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11
Q

Which antiepileptic has the highest teratigenicity risk and how do we address this?

A

Valproate has the highest teratogenic risk. Women should be on a PPP. Pregnancy Prevention Programme. Ideally it shouldnt be use in women that are pregnant

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12
Q

Topiramate carries with it an increase risk of what if used in the first trimester of pregnancy?

A

Cleft palate

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13
Q

Women taking antiepileptics meds are advised to take what before conception and during first trimester and why?

A

Folate supplementation or there will be neural tube defects

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14
Q

The concentration of antiepileptic drugs in the plasma can change during preganancy - doses of which 3 antiepileptics should be adjusted on the basis of plasma drug conc

A

Carbamazepine

Lamotrigine

Phenyltoin

(Cows lack Pills)

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15
Q

What should be monitored for pregnant women taking topiramate or levetiracetam

A

Fetal growth

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16
Q

What injection at birth minimises the risk of neonatal haemorrhage associated with antiepileptics

A

Injection of vitamin K helps minimise the risk of neonatal haemorrhage associated with ALL antiepileptics

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17
Q

Name three antiepileptics with an established risk of drowsiness in breast fed babies and that should be used with caution as a result

A

Benzodiazepines

Primidone

Phenobarbital

(BPP) Breast Protein Power

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18
Q

Carbamazepine may exacerbate what types of seizures and therefore should not be used?

A

“MATA”

Myoclonic

Absence

Tonic

Atonic

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19
Q

First line treatment option for absence seizures?

A

Ethosuximide

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20
Q

True or false: lamotrigine can exacerbate myoclonic seizures

A

True

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21
Q

True or false: valproate decreases the plasma concentration of lamotrigine

A

False - it increases it!

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22
Q

What’s responsible for the antiepileptic effects of primidone

A

It’s converted to phenobarbital

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23
Q

Antiepileptic licensed for adjunctive treatment of seizures in Lennox-gastaut syndrome

A

Rufinamide

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24
Q

Sodium valproate has widespread metabolic effects and monitoring of what is therefore essential

A

LFT FBC

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25
Q

Treatment options for seizures lasting longer than 5 minutes

A

IV lorazepam IV diazepam

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26
Q

There is a risk of what syndrome in patients with HLA-B*1502 allele for carbamazepine

A

Stevens-Johnson syndrome

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27
Q

For carbamazepine what’s the plasma concentration for optimum response

A

4-12mg/litre (20-50micromol/litre)

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28
Q

Name three things in the rosemont brand of gabapentin oral solution that exceed the WHO recommended limits if high doses are required

A

Propylene glycol

Acesulfame K (sweetner)

Saccharin sodium (sweetner)

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29
Q

Symptoms of phenytoin toxicity

A

Nystagmus

Ataxia (lack of coordinated muscle movement)

Confusion

Hyperglycaemia

Slurred speech

Diplopia (seeing double)

NACHSD

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30
Q

Name the prodrug of dexamfetamine

A

Lisdexamfetamine

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31
Q

The usual total plasma phenytoin concentration for optimum response is what?

A

10-20 mg/litre (or 40-80micromol/litre)

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32
Q

If you take topiramate in the first trimester of pregnancy what is there an increased risk of?

A

Cleft palate

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33
Q

Topiramate has been associated with what?

A

Associated with acute myopia with secondary angle-closure glaucoma

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34
Q

Plasma phenobarbital concentration for optimum response is what?

A

15-40 mg/litre (60-180 micromol/litre)

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35
Q

What can be used in palliative care to reverse the effects of midazolam

A

Flumazenil

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36
Q

Should modified release preparations of methylphenidate be prescribed by brand?

A

Yes

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37
Q

Symptoms of overdose of Amphetamines

A

Wakefulness

Excessive activity

Paranoia

Hallucinations

Hypertension

….Followed by exhaustion Convulsions Hyperthermia Coma

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38
Q

Long term use of lithium has been associated with what and requires what as a result

A

Thyroid disorders and mild cognitive and memory impairment - monitor thyroid function every 6 months

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39
Q

When should levels be taken for lithium and what’s the targets?

A

12 hours after dose Target: 0.4-1mmol/litre For acute episodes of mania the target is: 0.8-1mmol/litre

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40
Q

Drug interaction if introducing ACEI, NSAID or diuretic with lithium?

A

ACE + NSAID + Diuretic + Lithium = Renal impairment

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41
Q

Symptoms of lithium toxicity

A

Hypothyroidism Renal dysfunction Intracranial hypertension (headache + visual disturbances)

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42
Q

During the first few weeks of antidepressant treatment there is an increased risk of what?

A

Agitation Anxiety Suicidal ideation

(AAS)

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43
Q

What class of antidepressant is first line and why?

A

SSRIs - better tolerated and safer in overdose

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44
Q

What does St. John’s wort do to metabolising enzymes?

A

Induces drug metabolising enzymes

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45
Q

True or false: elderly patients may take longer to respond to antidepressants

A

True

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46
Q

Antidepressant therapy (particularly SSRIs) have been associated with hyponatraemia and can make what symptoms develop?

A

Confusion Drowsiness Convulsions (hence lowers seizure threshold when taken with antiepileptics)

CDC = hyponatremia

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47
Q

Characteristics of serotonin syndrome fall into what three categories

A

Neuromuscular hyperactivity Autonomic dysfunction Altered mental state

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48
Q

Symptoms associated with neuromuscular hyperactivity in serotonin syndrome

A

Myoclonus

Rigidity

Tremor

Hyperreflexia

Clonus

MR. THC

Are symptoms of what?

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49
Q

Symptoms associated with autonomic dysfunction in serotonin syndrome

A

Tachycardia

BP changes

Hyperthermia

Diaphoresis (Sweating)

Shivering

Diarrhoea

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50
Q

Symptoms associated with altered mental state in serotonin syndrome

A

Mania Agitation Confusion

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51
Q

Name the three less sedating TCAs & Related antidepressants

A

Imipramine Lofepramine Nortriptyline

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52
Q

True or false: low gastric pH causes reduced absorption of the paroxetine oral suspension

A

False - a high gastric pH reduces absorption of paroxetine oral susp

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53
Q

Name the group 1 phenothiazine derivative antipsychotics and what are their side effects

A

Chlorpromazine Levomepromazine Promazine Pronounced sedative Moderate antimuscarinic Moderate extrapyramidal

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54
Q

Name two butyrophenones and which class of the phenothiazine derivatives do they resemble?

A

Benperidol Haloperidol Group 3!

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55
Q

Name a diphenylbutylpiperidine

A

Pimozide

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56
Q

Name a substituted benzamide

A

Sulpiride

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57
Q

Aripiprazole reduces prolactin - why?

A

It’s only a dopamine receptor partial agonist

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58
Q

Which antipsychotics are most likely to cause symptomatic hyperprolactinaemia

A

Risperidone Amisulpride & First generations

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59
Q

Symptoms of hyperprolactinaemia

A

Sexual dysfunction

Reduced bone mineral density

Breast enlargement

Galactorrhoea

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60
Q

Antipsychotics have been associated with what cardiovascular side effects

A

Tachycardia

Arrhythmias

Hypotension

Prolong QT

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61
Q

All antipsychotics can cause weight gain and hyperglycaemia- which ones are of particular concern with causing diabetes?

A

Clozapine

Olanzapine

Quetiapine

Risperidone

CiROQ

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62
Q

Name a rare but potentially fatal side effect of all antipsychotic drugs and how long can it last for after discontinuation of the drug

A

Neuroleptic malignant syndrome 5-7 days

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63
Q

True or false: first generation antipsychotics are better at treating the negative symptoms of schizophrenia

A

False! Second generation are better

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64
Q

True or false: first generation antipsychotics are less likely to cause diabetes than the second generation

A

TRUE DAT

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65
Q

Haloperidol dose adjustments when?

A

If smoking started or stopped during treatment

66
Q

Monitoring requirements for pimozide (1st generation antipsychotic)

A

ECG- there’s been reports of unexplained sudden death - caution QT prolongation

67
Q

What’s the name given to the phenothiazines that explains the facial and skeletal muscle spasms and ocugyric crises

A

Acute dystonic reactions

68
Q

True or false: phenothiazines are hepatotoxic

A

True dat

69
Q

Is BP monitoring mandatory for sulpiride?

A

No- does not affect blood pressure as much as other antipsychotics

70
Q

Name four first generation antipsychotic depot injections

A

Flupentixol decanoate Fluphenazine decanoate Haloperidol decanoate Zuclopenthixol decanoate

71
Q

How can you treat hypersalivation side effect of clozapine

A

Hyoscine hydrobromide- aslong as patient not at risk of addictive antimuscarinic side effects of hyoscine and clozapine combined

72
Q

Treatment options for muscle cramps in motor neurone diseases

A

Quinine Baclofen Tizanidine Dantrolene Gabapentin

73
Q

Name three non ergot derived dopamine agonists used in Parkinson’s disease

A

Pramipexole Ropinirole Rotigotine

74
Q

Name three ergot derived dopamine agonists used in Parkinson’s

A

Bromocriptine Cabergoline Pergolide

75
Q

Why are ergot derived dopamine agonists used to a less extent than non ergot derived DA in Parkinson’s

A

Risk of fibrotic reactions

76
Q

What is apomorphine

A

Potent dopamine receptor agonist used in advanced Parkinson’s disease to help with off periods

77
Q

Name two dopa decarboxylase inhibitors

A

Benserazide Carbidopa

78
Q

Name two MAO type B inhibitors used in Parkinson’s

A

Rasagiline Selegiline Safinamide

79
Q

When would you introduce COMPT inhibitors in Parkinson’s disease

A

In patients on levodopa + dopa decarboxylase experiencing end of dose motor fluctuations

80
Q

When adding COMPT inhibitors to Parkinson’s meds regimen what may need to be reduced

A

Levodopa dose by around 10-30%

81
Q

Name three COMT inhibitors

A

Entacapone

Opicapone

Tolcapone

are all COMT inhibitors

82
Q

Why is there restrictions from the MHRA on the use of domperidone

A

It’s associated with a small increased risk of serious cardiac side effects

83
Q

What are the MHRA restrictions on domperidone

A

Only indicated for N&V lowest effective dose for max one week .

Contraindicated in cardiac conditions or at risk of QT prolong and in combo with CYP3A4 inhibitors.

Not in severe hepatic impairment Recommended dose in over 12 and over 35kg is 10mg up to TDS

Recommended dose in children under 35kg is 250mcg/kg up to TDS

84
Q

MHRA recommendations on metoclopramide

A

Particular indications Max 5 days treatment 10mg up to TDS - max daily dose 500mcg/kg IV slow plus over 3 mins

85
Q

What’s aprepitant and fosaprepitant

A

Neurokinin receptor antagonists used for nausea and vomiting - fosaprepitant is the prodrug of aprepitant

86
Q

MHRA warning about promethazine

A

Children under 6 years should not be given OTC cough and cold meds containing promethazine

87
Q

Pain in sickle cell disease

A

Paracetamol Ibuprofen Codeine/dihydrocodeine Morphine/diamorphine

88
Q

What painkiller should be avoided in sickle cell disease and why?

A

Pethidine - accumulation of a neurotoxic metabolite which can precipitate seizures

89
Q

Three drugs often adequate in dental pain

A

Paracetamol Ibuprofen Aspirin

90
Q

Side effects of Opioids

A

Nausea & vom Severe constipation Drowsiness Resp depression Dependence

91
Q

Which has longer duration of action: buprenorphine or morphine?

A

Buprenorphine

92
Q

Sublingual buprenorphine lasts how long

A

Subutex Lasts 6-8hrs

93
Q

Benefit of diamorphine in palliative care

A

Greater solubility means smaller injection volume, less nausea and less hypotension

94
Q

Fever/increased heat to buprenorphine patch can cause what

A

Increased absorption

95
Q

Methadone/buprenorphine for opioid dependence - supervised consumption should be for how long

A

3 months

96
Q

Max dose of codeine in adults

A

240mg (60mg QDS)

97
Q

Codeine is contraindicated in patients who are what metabolisers

A

Ultra rapid metabolisers (CYP2D6 ultra rapid metabolisers)

98
Q

Why are dispersive or effervescent analgesic preferred in migraine?

A

Peristalsis is reduced therefore reducing absorption

99
Q

Name the short acting Z drugs used for insomnia

A

Zaleplon Zolpidem Zopiclone

100
Q

Name three shorter acting benzodiazepines with little or no hangover effect

A

Loprazolam

Lormetazepam

Temazepam

101
Q

Caution/further information for benzodiazepines

A

Paradoxical effects - increase in hostility and aggression

102
Q

Three drugs used in narcolepsy

A

Sodium oxybate Pitolisant Modafinil

103
Q

Drug used in alcohol withdrawal

A

Chloridazepoxide

104
Q

Three drugs used in alcohol relapse prevention

A

Acomprosate Naltrexone Disulfiram (2nd line)

105
Q

Drug used to reduce alcohol intake

A

Nalmefene

106
Q

Two drugs used to treat nicotine dependence

A

Bupropion Varenicline

107
Q

Can you use nicotine replacement therapy and bupropion or varenicline together?

A

It’s not recommended

108
Q

Smoking induces what enzyme and which drugs should therefore be monitored

A

CYP1A2

Theophylline

Cinacalcet

Ropinirole

Antipsychotics (cloz, olanz, chlorpromazine, haloperidol)

109
Q

Which is more sedating- methadone or buprenorphine?

A

Methadone is more sedading than buprenorphine

110
Q

How long does it take methadone to reach steady state for patients on a stable dose and why?

A

3-10 days due to long half life

111
Q

Signs of neonatal withdrawal from opioids

A

High pitched cry Rapid breathing Hungry but ineffective suckling Excessive wakefulness Hypertonicity Convulsions

112
Q

MHRA/CHM advice with varenicline for nicotine dependence

A

Suicidal behaviour - discontinue if they develop agitation, depressed mood, suicidal thoughts

113
Q

Hypnotics in elderly can cause what

A

Ataxia Confusion Falls

114
Q

Long term treatment of bipolar disorder should continue for how long after the last manic episode

A

At least 2 yrs (5 yrs in those at risk of relapse)

115
Q

Name the MAOI that has the greatest stimulant action and therefore causes increased risk of hypertensive crisis

A

Tranylcypromine

116
Q

Which two MAOIs are more likely to cause hepatotoxicity than tranylcypromine

A

Phenelzine Isocarboxazid

117
Q

4 antipsychotics with increased risk of hyperglycaemia and weight gain

A

Clozapine Olanzapine Quetiapine Risperidone

118
Q

Two first generations that have less risk of causing diabetes

A

Fluphenazine Haloperidol

119
Q

Of the second generations which are less likely to cause diabetes &a weight gain

A

Amisulpride Aripiprazole

120
Q

For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product

A

Carbamazepine / Phenobarbital / Phenyltoin / Primidone

CPPP

121
Q

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. What other factors do we take into account?

A

We Consider Factors such as Seizure frequency and Treatment history.

Drugs are:

Valproate / Lamotrigine / Perampanel / Clozabam / Oxcarbazepine / Topiramate

CLOT P

122
Q

For these drugs, its usually unnessary to maintain a manufacturers product unless there’s specific conserns such as what?

A

Usually its ok to change unless the patient has anxiety. these drugs are

GELLT

Gabapentin.. Ethosuximide.. Lacosamide. Levetiracetam… Tiagabine

123
Q

Whats special about Benzodiazepines, Primodine and Phenobarbital?

A

They metabolise slowly in neonates and can cause drowsinessand so caution is neseccary

124
Q

How should antiepiletic mothers monitor their breastfeeding infants?

A

Monitor Breastfeeding infants for adequate weight gain/ developmental milestones/ feeding difficulties and over sedation

125
Q

What are Focal Seizures?

What are your first line options for treating newly diagnosed focal seizures? What’s next if not tolereated?

A

Result from abnormal activity in one part of the brain.

Can be with loss of consciousness

Can be without loss of consciousness :These seizures may also result in the involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.

Carbamazepine and Lamotrigine = First Line for newly diagnosed focal seizures

If it’s not tolerated, treat with Oxcarbazepine/ Sodium Valproate / Levetiracetam

126
Q

What is the Signs of a Tonic-Clonic Seizure? What is first line treatment for Tonic-Clonic seizures? and what to do if thats not tolerated?

A

most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting your tongue.

Sodium Valproate i n newly diagnosed tonic-clonic seizures (Except in females). Lamotrigine and Carbamazepine are the alternatives, but it may exacrbate an absence seizure.

127
Q

What is an Absence seizure and First line of treatment in an absence seizure?

A

often occur in children and are characterized by staring into space or by subtle body movements, such as eye blinking or lip smacking. Very brief loss of consciousness.

Ethosuximide OR Sodium Valproate (Except in pregnant women that are pre-menopausal). Ethosuximide can be used as adjunt therapy if its not effective

128
Q

Symptoms of Epilepsy?

A

sweaty palms too

129
Q

Common / Very Common ADRS of Carbamazepine?

A

Carbamazepine :

GI upset

Neurological effects eg dizziness and ataxia.

Mild skin rash.

antiepiletic hypersensitivity syndrome.

Odema and hypernatraemia

130
Q

Whats key about Phenyltoin?

A

Its a high risk drug of a narrow therapeutic index.

Binds to neuronal Na+ channels in their inactive state and prolongs activity.

It is a highly protein bound drug, and there is a reduced plasma free-drug concentration in:

Pregnancy, Children (Neonates <3 months), elderly and in liver failure.

They show early signs of toxicity.

131
Q

Tell me about switching Phenytoin products?

A
132
Q

Side Effects of Phenyltoin?

A

Other than the image:

Phenytoin induces Vitamin D metabolism. Consider Vit D supplements.

Hepatotoxicity. Signs: Dark Uring, N & V. Jaundice

133
Q

what unfortunate thing can all antiepileptic drugs create the idea of?

A

suicide

134
Q

Tell me about injected IV Phenytoin and Fosphenytoin

A
135
Q

Phenytoin interactions

A
136
Q

Carbamazepine use, therapeutic range and signs + signs and symptoms of Toxicity?

A
137
Q

Side effects of Carbamazepine and what preparations reduce side effects?

A

Modified preparations reduce side effects in the elderly

138
Q

Drug interactions of Carbmazepine

A
139
Q

What are your cognitive and non cognitive symptoms in Dementia?

A
140
Q

Drug Management in Dementia and when to stop etc?

A
141
Q

Which Antepileptics are enzyme inducers and which are inhibitors?

A
142
Q

Management of non cognitive symptoms in dementia?

A
143
Q

What are they key interactions of valproate?

A
144
Q

Whats the three types of Status Epilepticus?

A
145
Q

What classes as a epileptic medical emergency in the local community and how do we treat it

A
146
Q

Give me a Low-Down of the Physical and Psychological symptoms of anxiety

A
147
Q

What drugs are given in anxiety?

A
148
Q

How do BDZ work and what are its clinical manifestations?

A
149
Q

Side effects of BDZ and Use of BDZ?

A
150
Q

BDZ dependence what are the signs? and can we stop suddenly?

Onset time of symptoms?

How do we withdraw?

A
151
Q

what drugs interact with BDZ?

A
152
Q

types of epilepsy ND treatments for epilepsy

A
153
Q

What is Parkinsons in terms of signs and what is the available treatments for nausea and vomiting. Can i stop suddently?

A
154
Q

Symptoms of Parkinsons when its severe

A
155
Q
A
156
Q

how do you treat parkinsons in first line and how is it dosed to avoid?

A
157
Q

Levodopa side effects

A

excessive sleep.

158
Q

what is first line in patients experiencing motor symptoms in parkinsons that dont affect quality of life?

A

Non - ergot derived d2 antagonists such as pamiprexole

Rotigotine

OR given as an adjunct to levodopa

159
Q

warnings assocaited with Domperidone?`

A
160
Q

opiates side effects

A

British National Formulary (18 decks)

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