Chapter 4- Nervous System Flashcards
Name three anticholinesterase inhibitors used in dementia
Donepezil Rivastigmine Galantamine
Name the Glutamate receptor antagonist used in more severe dementia
Memantine
Name 4 antiepileptics that have long half lives and can be given once daily at bedtime
Lamotrigine Perampanel Phenobarbital Phenytoin
Name 4 antiepileptics in category 1 that are prescribed by brand
Phenytoin Carbamazepine Phenobarbital Primidone
Drugs that can cause Anti-epileptic syndrome?
Carbamazepine
Lacosamide
Lamotrignie
Oxcarbazepine
Phenobarbital
Primodine
Phenyltoin
Rufinamide
(Capsules lack lands once pharmacists poke physical reasons)
When can antiepileptic hypersensitivity syndrome start showing symptoms
Between 1 and 8 weeks of exposure
Symptoms of antiepileptic hypersensitivity syndrome
Fever
Rash
Lymphadenopathy
Liver, Haematological and Renal Pulmonary abnormalities
Vasculitis
Multi-organ failure
Frigid Raunchy Little Hampsters Redo Private Antisocial Verant Millions
Is there a risk of suicidal thoughts and behaviours with all antiepileptic drugs
Yes
What interactions occur with antiepileptics
Usually as a result of enzyme induction or inhibition
How do we withdraw antiepileptics?
All Antiepilepcitcs are withdrawn gradually and under supervision. Avoid Abrupt withdrawal particularly in barbituates and benzodiazepines as this can cause severe rebound seizures
Which antiepileptic has the highest teratigenicity risk and how do we address this?
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
Topiramate carries with it an increase risk of what if used in the first trimester of pregnancy?
Cleft palate
Women taking antiepileptics meds are advised to take what before conception and during first trimester and why?
Folate supplementation or there will be neural tube defects
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
Carbamazepine
Lamotrigine
Phenyltoin
(Cows lack Pills)
What should be monitored for pregnant women taking topiramate or levetiracetam
Fetal growth
What injection at birth minimises the risk of neonatal haemorrhage associated with antiepileptics
Injection of vitamin K helps minimise the risk of neonatal haemorrhage associated with ALL antiepileptics
Name three antiepileptics with an established risk of drowsiness in breast fed babies and that should be used with caution as a result
Benzodiazepines
Primidone
Phenobarbital
(BPP) Breast Protein Power
Carbamazepine may exacerbate what types of seizures and therefore should not be used?
“MATA”
Myoclonic
Absence
Tonic
Atonic
First line treatment option for absence seizures?
Ethosuximide
True or false: lamotrigine can exacerbate myoclonic seizures
True
True or false: valproate decreases the plasma concentration of lamotrigine
False - it increases it!
What’s responsible for the antiepileptic effects of primidone
It’s converted to phenobarbital
Antiepileptic licensed for adjunctive treatment of seizures in Lennox-gastaut syndrome
Rufinamide
Sodium valproate has widespread metabolic effects and monitoring of what is therefore essential
LFT FBC
Treatment options for seizures lasting longer than 5 minutes
IV lorazepam IV diazepam
There is a risk of what syndrome in patients with HLA-B*1502 allele for carbamazepine
Stevens-Johnson syndrome
For carbamazepine what’s the plasma concentration for optimum response
4-12mg/litre (20-50micromol/litre)
Name three things in the rosemont brand of gabapentin oral solution that exceed the WHO recommended limits if high doses are required
Propylene glycol
Acesulfame K (sweetner)
Saccharin sodium (sweetner)
Symptoms of phenytoin toxicity
Nystagmus
Ataxia (lack of coordinated muscle movement)
Confusion
Hyperglycaemia
Slurred speech
Diplopia (seeing double)
NACHSD
Name the prodrug of dexamfetamine
Lisdexamfetamine
The usual total plasma phenytoin concentration for optimum response is what?
10-20 mg/litre (or 40-80micromol/litre)
If you take topiramate in the first trimester of pregnancy what is there an increased risk of?
Cleft palate
Topiramate has been associated with what?
Associated with acute myopia with secondary angle-closure glaucoma
Plasma phenobarbital concentration for optimum response is what?
15-40 mg/litre (60-180 micromol/litre)
What can be used in palliative care to reverse the effects of midazolam
Flumazenil
Should modified release preparations of methylphenidate be prescribed by brand?
Yes
Symptoms of overdose of Amphetamines
Wakefulness
Excessive activity
Paranoia
Hallucinations
Hypertension
….Followed by exhaustion Convulsions Hyperthermia Coma
Long term use of lithium has been associated with what and requires what as a result
Thyroid disorders and mild cognitive and memory impairment - monitor thyroid function every 6 months
When should levels be taken for lithium and what’s the targets?
12 hours after dose Target: 0.4-1mmol/litre For acute episodes of mania the target is: 0.8-1mmol/litre
Drug interaction if introducing ACEI, NSAID or diuretic with lithium?
ACE + NSAID + Diuretic + Lithium = Renal impairment
Symptoms of lithium toxicity
Hypothyroidism Renal dysfunction Intracranial hypertension (headache + visual disturbances)
During the first few weeks of antidepressant treatment there is an increased risk of what?
Agitation Anxiety Suicidal ideation
(AAS)
What class of antidepressant is first line and why?
SSRIs - better tolerated and safer in overdose
What does St. John’s wort do to metabolising enzymes?
Induces drug metabolising enzymes
True or false: elderly patients may take longer to respond to antidepressants
True
Antidepressant therapy (particularly SSRIs) have been associated with hyponatraemia and can make what symptoms develop?
Confusion Drowsiness Convulsions (hence lowers seizure threshold when taken with antiepileptics)
CDC = hyponatremia
Characteristics of serotonin syndrome fall into what three categories
Neuromuscular hyperactivity Autonomic dysfunction Altered mental state
Symptoms associated with neuromuscular hyperactivity in serotonin syndrome
Myoclonus
Rigidity
Tremor
Hyperreflexia
Clonus
MR. THC
Are symptoms of what?
Symptoms associated with autonomic dysfunction in serotonin syndrome
Tachycardia
BP changes
Hyperthermia
Diaphoresis (Sweating)
Shivering
Diarrhoea
Symptoms associated with altered mental state in serotonin syndrome
Mania Agitation Confusion
Name the three less sedating TCAs & Related antidepressants
Imipramine Lofepramine Nortriptyline
True or false: low gastric pH causes reduced absorption of the paroxetine oral suspension
False - a high gastric pH reduces absorption of paroxetine oral susp
Name the group 1 phenothiazine derivative antipsychotics and what are their side effects
Chlorpromazine Levomepromazine Promazine Pronounced sedative Moderate antimuscarinic Moderate extrapyramidal
Name two butyrophenones and which class of the phenothiazine derivatives do they resemble?
Benperidol Haloperidol Group 3!
Name a diphenylbutylpiperidine
Pimozide
Name a substituted benzamide
Sulpiride
Aripiprazole reduces prolactin - why?
It’s only a dopamine receptor partial agonist
Which antipsychotics are most likely to cause symptomatic hyperprolactinaemia
Risperidone Amisulpride & First generations
Symptoms of hyperprolactinaemia
Sexual dysfunction
Reduced bone mineral density
Breast enlargement
Galactorrhoea
Antipsychotics have been associated with what cardiovascular side effects
Tachycardia
Arrhythmias
Hypotension
Prolong QT
All antipsychotics can cause weight gain and hyperglycaemia- which ones are of particular concern with causing diabetes?
Clozapine
Olanzapine
Quetiapine
Risperidone
CiROQ
Name a rare but potentially fatal side effect of all antipsychotic drugs and how long can it last for after discontinuation of the drug
Neuroleptic malignant syndrome 5-7 days
True or false: first generation antipsychotics are better at treating the negative symptoms of schizophrenia
False! Second generation are better
True or false: first generation antipsychotics are less likely to cause diabetes than the second generation
TRUE DAT
Haloperidol dose adjustments when?
If smoking started or stopped during treatment
Monitoring requirements for pimozide (1st generation antipsychotic)
ECG- there’s been reports of unexplained sudden death - caution QT prolongation
What’s the name given to the phenothiazines that explains the facial and skeletal muscle spasms and ocugyric crises
Acute dystonic reactions
True or false: phenothiazines are hepatotoxic
True dat
Is BP monitoring mandatory for sulpiride?
No- does not affect blood pressure as much as other antipsychotics
Name four first generation antipsychotic depot injections
Flupentixol decanoate Fluphenazine decanoate Haloperidol decanoate Zuclopenthixol decanoate
How can you treat hypersalivation side effect of clozapine
Hyoscine hydrobromide- aslong as patient not at risk of addictive antimuscarinic side effects of hyoscine and clozapine combined
Treatment options for muscle cramps in motor neurone diseases
Quinine Baclofen Tizanidine Dantrolene Gabapentin
Name three non ergot derived dopamine agonists used in Parkinson’s disease
Pramipexole Ropinirole Rotigotine
Name three ergot derived dopamine agonists used in Parkinson’s
Bromocriptine Cabergoline Pergolide
Why are ergot derived dopamine agonists used to a less extent than non ergot derived DA in Parkinson’s
Risk of fibrotic reactions
What is apomorphine
Potent dopamine receptor agonist used in advanced Parkinson’s disease to help with off periods
Name two dopa decarboxylase inhibitors
Benserazide Carbidopa
Name two MAO type B inhibitors used in Parkinson’s
Rasagiline Selegiline Safinamide
When would you introduce COMPT inhibitors in Parkinson’s disease
In patients on levodopa + dopa decarboxylase experiencing end of dose motor fluctuations
When adding COMPT inhibitors to Parkinson’s meds regimen what may need to be reduced
Levodopa dose by around 10-30%
Name three COMT inhibitors
Entacapone
Opicapone
Tolcapone
are all COMT inhibitors
Why is there restrictions from the MHRA on the use of domperidone
It’s associated with a small increased risk of serious cardiac side effects
What are the MHRA restrictions on domperidone
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
MHRA recommendations on metoclopramide
Particular indications Max 5 days treatment 10mg up to TDS - max daily dose 500mcg/kg IV slow plus over 3 mins
What’s aprepitant and fosaprepitant
Neurokinin receptor antagonists used for nausea and vomiting - fosaprepitant is the prodrug of aprepitant
MHRA warning about promethazine
Children under 6 years should not be given OTC cough and cold meds containing promethazine
Pain in sickle cell disease
Paracetamol Ibuprofen Codeine/dihydrocodeine Morphine/diamorphine
What painkiller should be avoided in sickle cell disease and why?
Pethidine - accumulation of a neurotoxic metabolite which can precipitate seizures
Three drugs often adequate in dental pain
Paracetamol Ibuprofen Aspirin
Side effects of Opioids
Nausea & vom Severe constipation Drowsiness Resp depression Dependence
Which has longer duration of action: buprenorphine or morphine?
Buprenorphine
Sublingual buprenorphine lasts how long
Subutex Lasts 6-8hrs
Benefit of diamorphine in palliative care
Greater solubility means smaller injection volume, less nausea and less hypotension
Fever/increased heat to buprenorphine patch can cause what
Increased absorption
Methadone/buprenorphine for opioid dependence - supervised consumption should be for how long
3 months
Max dose of codeine in adults
240mg (60mg QDS)
Codeine is contraindicated in patients who are what metabolisers
Ultra rapid metabolisers (CYP2D6 ultra rapid metabolisers)
Why are dispersive or effervescent analgesic preferred in migraine?
Peristalsis is reduced therefore reducing absorption
Name the short acting Z drugs used for insomnia
Zaleplon Zolpidem Zopiclone
Name three shorter acting benzodiazepines with little or no hangover effect
Loprazolam
Lormetazepam
Temazepam
Caution/further information for benzodiazepines
Paradoxical effects - increase in hostility and aggression
Three drugs used in narcolepsy
Sodium oxybate Pitolisant Modafinil
Drug used in alcohol withdrawal
Chloridazepoxide
Three drugs used in alcohol relapse prevention
Acomprosate Naltrexone Disulfiram (2nd line)
Drug used to reduce alcohol intake
Nalmefene
Two drugs used to treat nicotine dependence
Bupropion Varenicline
Can you use nicotine replacement therapy and bupropion or varenicline together?
It’s not recommended
Smoking induces what enzyme and which drugs should therefore be monitored
CYP1A2
Theophylline
Cinacalcet
Ropinirole
Antipsychotics (cloz, olanz, chlorpromazine, haloperidol)
Which is more sedating- methadone or buprenorphine?
Methadone is more sedading than buprenorphine
How long does it take methadone to reach steady state for patients on a stable dose and why?
3-10 days due to long half life
Signs of neonatal withdrawal from opioids
High pitched cry Rapid breathing Hungry but ineffective suckling Excessive wakefulness Hypertonicity Convulsions
MHRA/CHM advice with varenicline for nicotine dependence
Suicidal behaviour - discontinue if they develop agitation, depressed mood, suicidal thoughts
Hypnotics in elderly can cause what
Ataxia Confusion Falls
Long term treatment of bipolar disorder should continue for how long after the last manic episode
At least 2 yrs (5 yrs in those at risk of relapse)
Name the MAOI that has the greatest stimulant action and therefore causes increased risk of hypertensive crisis
Tranylcypromine
Which two MAOIs are more likely to cause hepatotoxicity than tranylcypromine
Phenelzine Isocarboxazid
4 antipsychotics with increased risk of hyperglycaemia and weight gain
Clozapine Olanzapine Quetiapine Risperidone
Two first generations that have less risk of causing diabetes
Fluphenazine Haloperidol
Of the second generations which are less likely to cause diabetes &a weight gain
Amisulpride Aripiprazole
For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product
Carbamazepine / Phenobarbital / Phenyltoin / Primidone
CPPP
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?
We Consider Factors such as Seizure frequency and Treatment history.
Drugs are:
Valproate / Lamotrigine / Perampanel / Clozabam / Oxcarbazepine / Topiramate
CLOT P
For these drugs, its usually unnessary to maintain a manufacturers product unless there’s specific conserns such as what?
Usually its ok to change unless the patient has anxiety. these drugs are
GELLT
Gabapentin.. Ethosuximide.. Lacosamide. Levetiracetam… Tiagabine
Whats special about Benzodiazepines, Primodine and Phenobarbital?
They metabolise slowly in neonates and can cause drowsinessand so caution is neseccary
How should antiepiletic mothers monitor their breastfeeding infants?
Monitor Breastfeeding infants for adequate weight gain/ developmental milestones/ feeding difficulties and over sedation
What are Focal Seizures?
What are your first line options for treating newly diagnosed focal seizures? What’s next if not tolereated?
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
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?
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.
What is an Absence seizure and First line of treatment in an absence seizure?
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
Symptoms of Epilepsy?
sweaty palms too
Common / Very Common ADRS of Carbamazepine?
Carbamazepine :
GI upset
Neurological effects eg dizziness and ataxia.
Mild skin rash.
antiepiletic hypersensitivity syndrome.
Odema and hypernatraemia
Whats key about Phenyltoin?
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.
Tell me about switching Phenytoin products?
Side Effects of Phenyltoin?
Other than the image:
Phenytoin induces Vitamin D metabolism. Consider Vit D supplements.
Hepatotoxicity. Signs: Dark Uring, N & V. Jaundice
what unfortunate thing can all antiepileptic drugs create the idea of?
suicide
Tell me about injected IV Phenytoin and Fosphenytoin
Phenytoin interactions
Carbamazepine use, therapeutic range and signs + signs and symptoms of Toxicity?
Side effects of Carbamazepine and what preparations reduce side effects?
Modified preparations reduce side effects in the elderly
Drug interactions of Carbmazepine
What are your cognitive and non cognitive symptoms in Dementia?
Drug Management in Dementia and when to stop etc?
Which Antepileptics are enzyme inducers and which are inhibitors?
Management of non cognitive symptoms in dementia?
What are they key interactions of valproate?
Whats the three types of Status Epilepticus?
What classes as a epileptic medical emergency in the local community and how do we treat it
Give me a Low-Down of the Physical and Psychological symptoms of anxiety
What drugs are given in anxiety?
How do BDZ work and what are its clinical manifestations?
Side effects of BDZ and Use of BDZ?
BDZ dependence what are the signs? and can we stop suddenly?
Onset time of symptoms?
How do we withdraw?
what drugs interact with BDZ?
types of epilepsy ND treatments for epilepsy
What is Parkinsons in terms of signs and what is the available treatments for nausea and vomiting. Can i stop suddently?
Symptoms of Parkinsons when its severe
how do you treat parkinsons in first line and how is it dosed to avoid?
Levodopa side effects
excessive sleep.
what is first line in patients experiencing motor symptoms in parkinsons that dont affect quality of life?
Non - ergot derived d2 antagonists such as pamiprexole
Rotigotine
OR given as an adjunct to levodopa
warnings assocaited with Domperidone?`
opiates side effects
