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Exam 2019 > 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 treatment should only be initiated under a specialist (however can then be managed in primary care)

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3
Q

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

A

Memantine

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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

Increased risk of stroke and a small increased risk of death

If needed, use the lowest effective dose and for the shortest time
Review every 6 weeks

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7
Q

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

A

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

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8
Q

What patient advice is needed for galantamine?

A

Risk of serious skin reaction including Stevens-Johnson

Stop taking if reaction occurs

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9
Q

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

A

Antiepileptic drugs have been divided into three risk-based categories to help healthcare professionals decide whether it is necessary to maintain continuity of supply of a specific manufacturer’s product.

Category 1:
Carbamazepine, phenobarbital, phenytoin, primidone. For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product.

Category 2
Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide. For these drugs, the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with the patient and/or carer taking into account factors such as seizure control

Category 3
Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin. For these drugs, it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed

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10
Q

What is antiepileptic hypersensitivity syndrome?

A

Rare but potentially fatal syndrome associated with some antiepileptic drugs

The symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy 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 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 reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis have developed (especially in children); most rashes occur in the first 8 weeks.

Risk factors include concomitant use of valproate, too high dose or too rapid dose increase

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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, hepatic or skin disorders
Antiepileptic hypersensitivity syndrome

Seek medical help if fever, rash, mouth ulcers etc occur

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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 reactions: these develop within 1-8 weeks. They include serious skin reactions i.e. Steven-
Johnson syndrome and toxic epidermal necrolysis

Blood disorders - Patients and their carers should be alert for symptoms and signs suggestive of bone-marrow failure, such as anaemia, bruising, or infection

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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/admnistration

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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?

A

Involuntary eye movement

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43
Q

What is diplopia?

A

Double vision

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44
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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45
Q

What are specific side effects with topiramate? Hint - eyes

A 
Acute myopia (near sightedness) with secondary angle-closure glaucoma
Encephalopathic symptoms - sedation, confusion
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46
Q

What is primidone used for?

A

Essential tremor

Epilepsy

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47
Q

What are specific side effects of IV phenytoin?

A

Bradycardia

Hypotension

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48
Q

What is buspirone used for?

A

Acute anxiety

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49
Q

What is a risk with IV diazepam?

A

Venous thrombophlebitis

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50
Q

What is methylphenidate used for?

A

ADHD

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51
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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52
Q

Can lithium lower seizure threshold?

A

Yes

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53
Q

Long term use of lithium has been associated with what?

A

Thyroid disorders

Mild cognitive and memory impairment

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54
Q

What are the signs of lithium toxicity?

A 
GI disturbances- vomiting and diarrhoea 
Visual disturbances, nystagmus (involuntary movement of the eyes) 
Polyuria - increased urination
Tremor
Restlessness 
CNS disturbances- confusion, drowsiness, lack of coordination 
Hypernatraemia 
Cardiac arrhythmias
Renal failure
Circulatory failure
Increased thirst
Memory impairment
Coma
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55
Q

When should lithium samples be taken?

A

12 hours post dose

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56
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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57
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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58
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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59
Q

What is lithium used for?

A 
Treatment and prophylaxis of:
Mania
Bipolar disorder
Recurrent depression
Aggressive/self harming behaviour
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60
Q

What class of drug is first line in depression?

A

SSRI

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61
Q

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

A

Sertraline

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62
Q

Are SSRIs or TCAs more sedating?

A

TCAs are more sedating

Also have more antimuscarinic and cardiotoxic side effects

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63
Q

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

A

Every 1-2 weeks

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64
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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65
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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66
Q

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

A

At least 2 years

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67
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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68
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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69
Q

True or false:

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

A

True

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70
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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71
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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72
Q

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

A

Benzodiazepine or buspirone

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73
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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74
Q

After how many weeks is anxiety classed as chronic?

A

4 weeks

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75
Q

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

A

SSRIs

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76
Q

What are the less sedating TCAs?

A

Imipramine hydrochloride, lofepramine, and nortriptyline.

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77
Q

If a patient is on an antidepressant and is going to be changed to an MAOI, what time period should they have stopped the previous antidepressant?

A

2 weeks

3 weeks if starting clomipramine or imipramine

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78
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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79
Q

MAOI interactions can persist for how long after discontinuing MAOI?

A

2 weeks

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80
Q

Can SSRIs cause QT prolongation?

A

Yes

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81
Q

What type of drug is duloxetine?

A

SNRI

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82
Q

What type of drug is venlafaxine?

A

SNRI

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83
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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84
Q

What are SSRIs cautioned in?

A

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

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85
Q

Can mirtazapine cause QT prolongation?

A

Yes

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86
Q

What is the patient advice regarding mirtazapine?

A

Blood disorders- report fever, sore throat etc

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87
Q

Can TCAs cause QT prolongation?

A

Yes

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88
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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89
Q

What class of drug is dosulepin?

A

TCA

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90
Q

What are the symptoms of TCA overdose?

A 
Hypotension
Hypothermia
Convulsions
Respiratory failure
Dilated pupils
Urinary retention
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91
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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92
Q

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

A

More effective on the positive symptoms

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93
Q

What are the main side effects of antipsychotics?

A
  • Extrapyramidal side effects - parkinsonism, dystonia, tardive dyskinesia
  • Hyperprolactinaemia
  • Sexual dysfunction
  • Cardiovascular - QT prolongation, hypotension, arrhythmias
  • Hyperglycaemia, diabetes
  • Weight gain
  • Hypo/hyperthermia
  • Neuroleptic malignant syndrome
  • Blood dyscrasias
  • Photosensitisation
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94
Q

What is dystonia?

A

Abnormal face/body movements

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95
Q

Which antipsychotic is least likely to cause hyperprolactinaemia?

A

Ariprazole

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96
Q

Which antipsychotics are most likely to cause hyperprolactinaemia?

A

Risperidone, amisulpride, first generation antipsychotics

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97
Q

Which antipsychotics carry the highest risk of QT prolongation?

A

Haloperidol

Pimozide

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98
Q

Which antipsychotics commonly cause weight gain?

A

Clozapine

Olanzipine

99
Q

Which antipsychotics commonly cause hyperglycaemia and diabetes?

A

Clozapine
Olanzipine
Risperidone
Quetiapine

100
Q

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

A

Second generation

101
Q

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

A

Second generation

102
Q

Which antipsychotic is least likely to cause QT prolongation?

A

Aripriprazole

103
Q

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

A

Second generation is more likely

104
Q

Which antipsychotics are least likely to cause weight gain?

A

Ariprazole
Hapoperidol
Amisulpride

105
Q

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

A

4-6 weeks

106
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

107
Q

True or false:

Clozapine patients must be registered with a clozapine patient monitoring service

A

True

108
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

109
Q

What is the MHRA advice regarding clozapine?

A

Potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus

If constipation develops, seek immediate medical advice

110
Q

What are the specific side effects with clozapine?

A
  • Agranulocytosis
  • Cardiomyopathy
  • Intestinal obstruction
  • Hypersalivation
111
Q

How does clozapine interact with smoking?

A

Smoking breaks down clozapine so a higher dose may be needed

112
Q

Is haloperidol a first or second generation antipsychotic?

A

First

113
Q

Is olanzapine a first or second generation antipsychotic?

A

Second

114
Q

Is clozapine a first or second generation antipsychotic?

A

Second

115
Q

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

A

Impulse control disorders e.g. gambling, binge eating

116
Q

What is the patient advice regarding co-benelodopa?

A

Sudden onset of sleep

Caution when driving/operating machinery

117
Q

Madopar contains which drug?

A

Co-beneldopa

118
Q

Sinemet contains which drug?

A

Co-careldopa

119
Q

Stalevo contains which drug combination?

A

Levodopa, carbidopa, entacapone

120
Q

What neurological condition is amantadine used in?

A

Parkinson’s Disease

121
Q

What is apomorphine used for?

A

Advanced Parkinson’s Disease - “off” episodes

To combat the associated nausea and vomiting side effects, you can use domperidone but only short term (due to QT prolongation risk with domperidone and apomorphine used together)

122
Q

What is the important safety information regarding bromocriptine and cabergoline?

A

Associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions.

Impulse control disorders

123
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

124
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).

125
Q

Levodopa is associated with what side effect?

A

Motor complications, including response fluctuations (on and off periods) and dyskinesias

However, the overall motor improvement is more noticeable with levodopa

126
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

127
Q

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

A

Midodrine

128
Q

What is an advantage of domperidone over metoclopramide?

A

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

129
Q

What is aprepitant used for?

A

Nausea and vomiting in chemotherapy

130
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

131
Q

What is Hyperemesis gravidarum?

A

Severe vomiting in pregnancy

132
Q

In Hyperemesis gravidarum what vitamin supplementation should be considered?

A

Thiamine to reduce the risk of Wernicke’s

133
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

134
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

135
Q

Can ondansetron cause QT prolongation?

A

Yes

136
Q

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

A

Slow onset of action

137
Q

What are the weak opioids?

A

Codeine
Dihydrocodeine
Meptazinol

138
Q

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

A

<50kg

15mg/kg

139
Q

What are the side effects of opioid analgesics?

A
  • Constipation
  • Nausea
  • Respiratory depression
  • Drowsiness
  • Dependence and withdrawal
  • Overdose - pinpoint pupils, coma
140
Q

What is the MHRA warning regarding codeine?

A

Restricted use in children due to reports of morphine toxicity
Codeine should only be used to relieve acute moderate pain in children older than 12 years and only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone. A significant risk of serious and life-threatening adverse reactions has been identified in children with obstructive sleep apnoea who received codeine after tonsillectomy or adenoidectomy

141
Q

What is a potential side effect of IV fentanyl?

A

Muscle rigidity (may involve thoracic muscles)

142
Q

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

A

Increased absorption of drug

143
Q

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

A

May increase absorption

144
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

145
Q

What is the difference between oxynorm and oxycontin?

A

Oxynorm- immediate release oxycodone

Oxycontin- modified release oxycodone

146
Q

What is the difference between Shortec and Longtec

A

Shortec- immediate release oxycodone

Longtec- modified release oxycodone

147
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

148
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
149
Q

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

A

Propranolol

150
Q

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

A

Treatment of peripheral neuropathic pain in non-diabetic patients

151
Q

Capsaicin cream 0.075% is licensed in what?

A

Post herpetic neuralgia
Painful diabetic neuropathy
Osteoarthritis

152
Q

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

A

Short acting

153
Q

Is diazepam short or long acting?

A

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

154
Q

Is lorazepam short or long acting?

A

Short acting - little or no hangover effect

155
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

156
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)

157
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

158
Q

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

A

Buprenorphine or methadone

159
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

160
Q

What is first line for alcohol dependence?

What would be an alternative?

A

Acamprosate or naltrexone in combination with a psychological intervention

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

161
Q

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

A

Thiamine

162
Q

What is the patient advice regarding disulfiram?

A

Should be counselled on the disulfiram-alcohol reaction—reactions may occur following exposure to small amounts of alcohol found in perfume, aerosol sprays, or low alcohol and “non-alcohol” beers and wines; symptoms may be severe and life-threatening and can include nausea, flushing, palpitations, arrhythmias, hypotension, respiratory depression, and coma.

Patients and their carers should be counselled on the signs of hepatotoxicity—patients should discontinue treatment and seek immediate medical attention if they feel unwell or symptoms such as fever or jaundice develop.

163
Q

What is varenicline used for?

A

Smoking cessation

Brand name= Champix

164
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.

165
Q

What monitoring does clozapine require?

A

Monitor leucocyte and differential blood counts. Clozapine requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly as part of the clozapine patient monitoring service

Blood lipids and weight at baseline

FASTING blood glucose baseline

Baseline prolactin

166
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

167
Q

When should lithium be stopped before major surgery?

A

24 hours

168
Q

Ethosuximide is used for what type of seizures?

A

Absence

Myoclonic

169
Q

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

Valproate
Phenytoin
Carbamazepine
Lamotrigine

A

Valproate

170
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)

171
Q

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

A

Phenytoin

172
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
173
Q

What is the risk of abrupt lithium withdrawal?

How should it be withdrawn?

A

Increases the risk of relapse

The dose should be reduced gradually over a period of at least 4 weeks (preferably over a period of up to 3 months).

174
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.

175
Q

How does lithium interact with ACEis?

A

Risk of lithium toxicity

Excretion of lithum reduced by ACEi

176
Q

How does lithium interact with NSAIDs?

A

Risk of lithium toxicity

Excretion of lithium probably reduced by NSAIDs

177
Q

How does lithium interact with loop and thiazide diuretics?

A

Excretion of lithium reduced by Loop and Thiazide – Sodium depletion

178
Q

How does lithium interact with amiodarone?

A

Risk of ventricular arrhythmias

179
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

180
Q

Are preparations containing phenytoin sodium and phenytoin base bioequivalent?

A

No

181
Q

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

A

Can cause gingival hyperplasia

182
Q

How does phenytoin interact with NSAIDs?

A

Effect of phenytoin enhanced by NSAIDs

183
Q

How does phenytoin interact with amiodarone?

A

Amiodarone inhibits metabolism of phenytoin

184
Q

How does phenytoin interact with warfarin?

A

Phenytoin accelerates metabolism of warfarin

185
Q

How does phenytoin interact with cimetidine?

A

Cimetidine inhibits the metabolism of phenytoin

186
Q

How does phenytoin interact with fluoxetine?

A

Phenytoin concentration increased by fluoxetine

187
Q

How does phenytoin interact with St John’s Wort?

A

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

188
Q

Is lithium use associated with hyper or hypothyroidism?

A

Hypothyroidism

189
Q

Which of these side effects is not associated with lithium?

Hyperthyroidism
Tremors
Increased urination/thirst
Leukocytosis

A

Hyperthyroidism

Associated with hypothyroidism

190
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)

191
Q

Has diazepam got a short or long half life?

A

Long half life

192
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

193
Q

Are typical antipsychotics first or second generation antipsychotics?

A

First generation

194
Q

Are atypical antipsychotics first or second generation antipsychotics?

A

Second generation

195
Q

What antibiotic class can result in carbamazepine toxicity?

A

Macrolides

196
Q

What antidepressant can be used for smoking cessation?

A

Bupropion

197
Q

Carbamazepine commonly causes what electrolyte imbalance?

A

Hyponatraemia

198
Q

True or false:

Phenytoin is not known to cause skin pigmentation

A

False

Causes yellow-brown pigmentation

199
Q

What is the advice surrounding antipsychotics and sunlight?

A

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

200
Q

What is the general advice regarding monitoring patients on antipsychotics?

A

ECG may be required before treatment
Monitor prolactin concentration at the start of therapy, at 6 months, and then yearly.

Patients with schizophrenia should have physical health monitoring (including cardiovascular disease risk assessment) at least once per year.

201
Q

What is the advice regarding treatment cessation of antipsychotic drugs?

A

There is a high risk of relapse if medication is stopped after 1–2 years. Withdrawal of antipsychotic drugs after long-term therapy should always be gradual and closely monitored to avoid the risk of acute withdrawal syndromes or rapid relapse. Patients should be monitored for 2 years after withdrawal of antipsychotic medication for signs and symptoms of relapse.

202
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

If prescribing an AChE inhibitor (donepezil, galantamine, or rivastigmine), treatment should normally be started with the drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, an alternative AChE inhibitor could be prescribed if it is considered appropriate

203
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

204
Q

What are the contraindications for benzodiazepines?

A

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

205
Q

Selegiline is what type of drug?

A

Monoamine oxidase B inhibitor

206
Q

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

A

Selegiline

207
Q

What parkinsons disease drug colours your urine reddish brown?

A

Entacapone

208
Q

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

A

Amantadine

209
Q

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

A

Selegiline

210
Q

How do you manage status epilepticus?

A
  • IV lorazepam if seizure has lasted more than 5 minutes
  • Must have resuscitation facilities available (if not, use rectal diazepam or buccal midazolam although absorption is slower)
  • Can administer lorazepam again after 10 mins if no response
  • If after 25 minutes after onset and no response, give phenytoin (slow IV)/fosphenytoin (can be given more rapidly) /phenobarbital
  • If after 45 minutes after onset and no response, sedate patient
211
Q

Treatment with domperidone should not exceed how many days?

A

7 days

212
Q

Treatment with metoclopramide should not exceed how many days?

A

5 days

213
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

214
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.

215
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

216
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

217
Q

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

A

Buprenorphine

218
Q

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

Methadone
Buprenoprhine

A

Methadone

Has more severe withdrawal symptoms

219
Q

Which of the following can you titrate faster:

Methadone
Buprenoprhine

A

Buprenoprhine - can titrate within 1 week

Methadone can take several weeks

220
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

221
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

222
Q

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

A

2nd

223
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.

224
Q

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

A

Drug metabolism can be increased in the third trimester; it may be necessary to either increase the dose of methadone hydrochloride or change to twice-daily consumption (or a combination of both strategies) to prevent withdrawal symptoms from developing.

225
Q

What is the advice regarding opioid substitution during breastfeeding?

What red flag symptoms should you look out for?

A

Doses of methadone and buprenorphine should be kept as low as possible in breast-feeding mothers. Increased sleepiness, breathing difficulties, or limpness in breast-fed babies of mothers taking opioid substitutes should be reported urgently to a healthcare professional

226
Q

What is lofexidine used for?

A

Management of symptoms of opioid withdrawal

Can be prescribed as an adjuvant to opioid substitution therapy

227
Q

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

A

Their local NHS Stop smoking services

228
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)

229
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

230
Q

Can varenicline be used alongside NRT?

A

No

231
Q

Can varenicline be used alongside bupropion for smoking cessation?

A

No

232
Q

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

A

2 weeks with an assessment just before their supply finishes

233
Q

Can e-cigarettes be supplied by smoking cessation services?

A

No

234
Q

When should NRT be used in smoking pregnant patients?

A

Only if non-drug treatment options have failed

235
Q

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

A 
Theophylline
Clozapine
Olanzapine
Haloperidol
Chlorpromazine 
Ropinerole 
Cinacalcet
236
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
237
Q

Abnormal dreams can occur with which NRT preparation?

A

Patch- this is reduced if removed before bed

238
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

239
Q

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

A

7-14 days before

240
Q

Are e-cigs licensed is smoking cessation?

A

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

241
Q

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

A

10 ppm or less

242
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

243
Q

How many weeks is a course of varenicline?

A

12 weeks

244
Q

Capsaicin 0.025% cream is licensed for what?

A

Symptomatic relief in osteoarthritis

Exam 2019 (21 decks)

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