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
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)
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
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
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
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
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
8
Q
What patient advice is needed for galantamine?
A
Risk of serious skin reaction including Stevens-Johnson
Stop taking if reaction occurs
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
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.
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
12
Q
True or false:
Routine injection of vitamin K at birth minimises the risk of neonatal haemorrhage associated with antiepileptics.
A
True
13
Q
What is 1st line for newly diagnosed focal seizures?
A
Carbamazepine or Lamotrigine
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
15
Q
What is 1st line for absence seizures?
What would be an alternative?
A
Ethosuximide or sodium valproate
Lamtorogine is an alternative
16
Q
What is 1st line for myoclonic seizures?
What would be alternative options?
A
Sodium valproate
Topiramate or levetiracetam
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
18
Q
Which benzodiazepines can be used in epilepsy management (not status epilepticus)?
A
Clobazam
Clonazepam
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
20
Q
IV diazepam is effective in seizures but carries a high risk of what?
A
Thrombophlebitis
21
Q
True or false:
Diazepam IM or suppositories should be used for status epilepticus
A
False- absorption is too slow
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
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.
24
Q
Is long term anticonvulsant prophylaxis recommended?
A
Rarely indicated
25
If an epileptic patient becomes pregnant, what supplement is recommended alongside their pregnancy, especially in the first trimester?
Folate supplementation to prevent neural tube defects
High dose 5mg OD
26
Pregnant patients who are taking what antiepileptics should have fetal growth monitoring?
Topiramate or levetiracetam
27
What conditions can lamotrigine exacerbate?
Parkinson's Disease
| Myoclonic seizures
28
What is a main side effect of lamotrigine?
What are the risk factors of this?
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
29
What is the patient advice surrounding lamotrigine?
- 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.
30
What vitamin supplementation should you consider if a patient is on carbamazepine?
Vitamin D
| Especially if immobilised for long periods, or who have inadequate sun exposure/dietary intake of calcium
31
What are the main side effects to look out for if a patient is on carbamazepine?
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
32
What is an important side effect to look out for with ethosuximide?
Blood disorders (fever, mouth ulcers, or bleeding develops)
33
What severe side effect is associated with fosphenytoin (used for status epilepticus)?
Associated with severe cardiovascular reactions- asystole, ventricular fibrillation. Observe patient for at least 30 minutes after infusion
34
What is the MHRA advice regarding gabapentin?
Risk of severe respiratory depression
35
What are the serious side effects of lamotrigine?
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
36
What antiepileptic is licensed for migraine prophylaxis?
Topiramate
37
What vitamin supplementation should you consider if a patient is on sodium valproate?
Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.
38
What types of toxicity is associated with sodium valproate?
Blood disorders
Hepatic failure
Pancreatitis
39
What is the safety alert associated with injectable phenytoin?
Risk of death and severe harm from error with the prescribing/preparation/administration
40
What vitamin supplementation should you consider if a patient is on phenytoin?
Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.
41
What are the symptoms of phenytoin toxicity?
Nystagmus (involuntary eye movement), diplopia (double vision), slurred speech, ataxia, confusion, and hyperglycaemia
42
What is nystagmus?
Involuntary eye movement
43
What is diplopia?
Double vision
44
What is the patient advice surrounding phenytoin?
Can cause agranulocytosis- Recognise signs of blood or skin disorders- report if mouth ulcer, bruising, bleeding develops
Antiepileptic sensitivity syndrome
45
What are specific side effects with topiramate? Hint - eyes
```
Acute myopia (near sightedness) with secondary angle-closure glaucoma
Encephalopathic symptoms - sedation, confusion
```
Patients should report signs of raised intra-ocular pressure
46
What is primidone used for?
Essential tremor
| Epilepsy
47
What are specific side effects of IV phenytoin?
Bradycardia
| Hypotension
48
What is buspirone used for?
Acute anxiety
49
What is a risk with IV diazepam?
Venous thrombophlebitis
50
What is methylphenidate used for?
ADHD
51
How long should bipolar therapy be for?
For at least two years from the last manic episode and up to five years if the patient has risk factors for relapse.
52
Can lithium lower seizure threshold?
Yes
53
Long term use of lithium has been associated with what?
Thyroid disorders
| Mild cognitive and memory impairment
54
What are the signs of lithium toxicity?
```
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
```
55
When should lithium samples be taken?
12 hours post dose
56
How often should serum lithium monitoring take place in the initial and continuous treatment phase?
Weekly initially
Weekly after every dose change
3 months thereafter
57
What should you test/measure before starting lithium treatment?
```
Cardiac- ECG - can prolong QT
Renal function
Thyroid function
Blood count - can cause leukocytosis
Body weight - dosing for Priadel is based on weight
```
58
Once initiated on lithium therapy, how often should you measure BMI, electrolytes, eGFR and thyroid function?
Every 6 months
59
What is lithium used for?
```
Treatment and prophylaxis of:
Mania
Bipolar disorder
Recurrent depression
Aggressive/self harming behaviour
```
60
What class of drug is first line in depression?
SSRI
61
In patients with a history of unstable angina or recent MI, what is the most appropriate antidepressant?
Sertraline
62
Are SSRIs or TCAs more sedating?
TCAs are more sedating
| Also have more antimuscarinic and cardiotoxic side effects
63
How often should patients be reviewed at the start of antidepressant treatment?
Every 1-2 weeks
64
Antidepressant treatment should be continued for at least how many weeks before you consider switching?
How many weeks is this in the elderly?
4 weeks
6 weeks in the elderly as they may take longer to respond
65
Following first remission, how long should antidepressant treatment be continued for?
How long in the elderly?
At least 6 months
12 months in the elderly
66
Patients with recurrent depression should receive maintenance treatment for how long?
At least 2 years
67
How long should antidepressant treatment be continued for in generalised anxiety disorder?
At least 12 months as risk of relapse is high
68
What electrolyte imbalance is associated with antidepressants?
Which class of antidepressant is this the most common in?
Low sodium
SSRIs
Hyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.
69
True or false:
The use of antidepressants has been linked with suicidal thoughts and behaviour
True
70
What are the symptoms of serotonin syndrome?
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).
71
If a patient fails to respond to their first line SSRI treatment for depression, what would be the options?
Increasing the dose
Switching to a different SSRI or mirtazapine
Other 2nd line options:
Lofepramine (TCA), moclobemide (reversible MAOI), and reboxetine (NRI)
72
Management of acute anxiety involves the use of what drug class options?
Benzodiazepine or buspirone
73
For chronic anxiety, what is used?
Antidepressant - SSRI
If patient cannot tolerate SSRI, pregabalin can be considered
Benzodiazepine may be needed until the antidepressant starts to work
74
After how many weeks is anxiety classed as chronic?
4 weeks
75
Panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder are treated with what drug class?
SSRIs
76
What are the less sedating TCAs?
Imipramine hydrochloride, lofepramine, and nortriptyline.
77
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?
2 weeks
3 weeks if starting clomipramine or imipramine
78
What is the patient advice surrounding MAOIs?
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
79
MAOI interactions can persist for how long after discontinuing MAOI?
2 weeks
80
Can SSRIs cause QT prolongation?
Yes
81
What type of drug is duloxetine?
SNRI
82
What type of drug is venlafaxine?
SNRI
83
What type of drug is trazadone and what is it used for?
Serotonin uptake inhibitor
Depression particularly when sedation is required
84
What are SSRIs cautioned in?
Cardiac disease
Bleeding- especially GI
Epilepsy as they can cause seizures
85
Can mirtazapine cause QT prolongation?
Yes
86
What is the patient advice regarding mirtazapine?
Blood disorders- report fever, sore throat etc
87
Can TCAs cause QT prolongation?
Yes
88
Which antidepressant class is associated with a high rate of fatality?
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
89
What class of drug is dosulepin?
TCA
90
What are the symptoms of TCA overdose?
```
Hypotension
Hypothermia
Convulsions
Respiratory failure
Dilated pupils
Urinary retention
```
91
What do you need to consider in terms of the dose in patients on oral antipsychotics that require a change to IM?
IM bypasses first pass metabolism so consider a lower dose than that of the oral
92
In schizophrenia, are antipsychotics more effective on the negative or positive symptoms?
More effective on the positive symptoms
93
What are the main side effects of antipsychotics?
- 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
94
What is dystonia?
Abnormal face/body movements
95
Which antipsychotic is least likely to cause hyperprolactinaemia?
Ariprazole
96
Which antipsychotics are most likely to cause hyperprolactinaemia?
Risperidone, amisulpride, first generation antipsychotics
97
Which antipsychotics carry the highest risk of QT prolongation?
Haloperidol
| Pimozide
98
Which antipsychotics commonly cause weight gain?
Clozapine
| Olanzipine
99
Which antipsychotics commonly cause hyperglycaemia and diabetes?
Clozapine
Olanzipine
Risperidone
Quetiapine
100
Are first or second generation antipsychotics better at treating negative symptoms of schizophrenia?
Second generation
101
If extra-pyramidal side effects are a concern, should first or second generation antipsychotics be prescribed?
Second generation
102
Which antipsychotic is least likely to cause QT prolongation?
Aripriprazole
103
Are first or second generation antipsychotics more likely to cause insulin resistance and diabetes?
Second generation is more likely
104
Which antipsychotics are least likely to cause weight gain?
Ariprazole
Haloperidol
Amisulpride
105
Patients should receive an antipsychotic for how many weeks before it is deemed ineffective?
4-6 weeks
106
When should clozapine be used in schizophrenia?
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
True or false:
| Clozapine patients must be registered with a clozapine patient monitoring service
True
108
What monitoring is required at the start of antipsychotic treatment?
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
What is the MHRA advice regarding clozapine?
Potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus
If constipation develops, seek immediate medical advice
110
What are the specific side effects with clozapine?
- Agranulocytosis
- Cardiomyopathy
- Intestinal obstruction
- Hypersalivation
111
How does clozapine interact with smoking?
Smoking breaks down clozapine so a higher dose may be needed
112
Is haloperidol a first or second generation antipsychotic?
First
113
Is olanzapine a first or second generation antipsychotic?
Second
114
Is clozapine a first or second generation antipsychotic?
Second
115
What is the important safety information associated with dopamine-receptor antagonists e.g. levodopa?
Impulse control disorders e.g. gambling, binge eating
116
What is the patient advice regarding co-benelodopa?
Sudden onset of sleep
| Caution when driving/operating machinery
117
Madopar contains which drug?
Co-beneldopa
118
Sinemet contains which drug?
Co-careldopa
119
Stalevo contains which drug combination?
Levodopa, carbidopa, entacapone
120
What neurological condition is amantadine used in?
Parkinson's Disease
121
What is apomorphine used for?
How do you manage the associated nausea and vomiting side effect?
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
What is the important safety information regarding bromocriptine and cabergoline?
Associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions.
Impulse control disorders
123
What would be first line in the following condition:
A patient with Parkinson's whose motor symptoms are decreasing their quality of life
Co-carelopda or co-benelopda
124
What would be first line in the following condition:
A patient with Parkinson's whose motor symptoms are NOT affecting their quality of life
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
Levodopa is associated with what side effect?
Motor complications, including response fluctuations (on and off periods) and dyskinesias
Take at specific times of the day to avoid "off" periods
However, the overall motor improvement is more noticeable with levodopa
126
Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered what?
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
If drug therapy is required for a Parkinson's Disease patient who develops postural hypotension, what is considered as first line?
Midodrine
128
What is an advantage of domperidone over metoclopramide?
Less readily crosses the BBB so less likely to cause sedation and dystonic reactions
129
What is aprepitant used for?
Nausea and vomiting in chemotherapy
130
If vomiting during the first trimester of pregnancy is severe and requires drug therapy, what is used?
Short term antihistamine e.g. promethazine
131
What is Hyperemesis gravidarum?
Severe vomiting in pregnancy
132
In Hyperemesis gravidarum what vitamin supplementation should be considered?
Thiamine to reduce the risk of Wernicke's
133
What is the MHRA warning associated with domperidone?
Risk of cardiac side effects
QT prolongation
Max treatment duration should not normally exceed 1 week
134
What is the MHRA warning associated with metoclopramide?
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
Can ondansetron cause QT prolongation?
Yes
136
What is the problem with enteric coated aspirin in acute pain?
Slow onset of action
137
What are the weak opioids?
Codeine
Dihydrocodeine
Meptazinol
138
At what body weight should IV paracetamol be adjusted and what dose should you use?
<50kg
| 15mg/kg
139
What are the side effects of opioid analgesics?
- Constipation
- Nausea
- Respiratory depression
- Drowsiness
- Dependence and withdrawal
- Overdose - pinpoint pupils, coma
140
What is the MHRA warning regarding codeine?
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
What is a potential side effect of IV fentanyl?
Muscle rigidity (may involve thoracic muscles)
142
Why should you monitor patients using fentanyl patches if they have a fever?
Increased absorption of drug
143
Why mustn't you expose fentanyl patches to heat e.g. baths and saunas?
May increase absorption
144
True or false:
Pethidine has multiple strengths in tablet form
False- only has 50mg strength so do not legally need to state the strength on the prescription
145
What is the difference between oxynorm and oxycontin?
Oxynorm- immediate release oxycodone
| Oxycontin- modified release oxycodone
146
What is the difference between Shortec and Longtec
Shortec- immediate release oxycodone
| Longtec- modified release oxycodone
147
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.
True
148
In what situations would you consider migraine prophylaxis?
- 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
What is the most commonly used beta blocker for migraine prophylaxis?
Propranolol
150
A self adhesive capsaicin patch 8% is licensed in what?
Treatment of peripheral neuropathic pain in non-diabetic patients
151
Capsaicin cream 0.075% is licensed in what?
Post herpetic neuralgia
Painful diabetic neuropathy
Osteoarthritis
152
Is withdrawal is more common with the short or long acting benzodiazepines?
Short acting
153
Is diazepam short or long acting?
Long acting - good for if insomnia is associated with daytime anxiety
154
Is lorazepam short or long acting?
Short acting - little or no hangover effect
155
What kind of effect can happen as a result of taking benzodiazepines?
Paradoxical effects
| A paradoxical increase in hostility and aggression may be reported by patients taking benzodiazepines
156
Why are benzodiazepines cautioned in hepatic impairment?
If they are needed, are short or long acting ones recommended?
Can precipitate coma
Short acting
(However, in alcohol withdrawal, a long acting e.g. chordiazepoxide or diazepam is used via fixed dosed regimen)
157
For patients on opioid maintenance therapy, what should happen if they miss:
1) 3 or more days
2) 5 or more days
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
For opioid addiction, what can be used for opioid maintenance therapy?
Buprenorphine or methadone
159
Is buprenorphine or methadone more sedating?
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
What is first line for alcohol dependence?
What would be an alternative?
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
What should be given to alcohol dependent patients who are at risk of Wernicke's encephalopathy?
Thiamine
162
What is the patient advice regarding disulfiram?
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
What is varenicline used for?
Smoking cessation
| Brand name= Champix
164
What is the MHRA advice regarding varenicline?
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
What monitoring does clozapine require?
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
If it does need diluting, IV phenytoin should be administered in what fluid via what and why?
Sodium chloride
| Via large vein, in line phenytoin filter is needed as it precipitates easily
167
When should lithium be stopped before major surgery?
24 hours
168
Ethosuximide is used for what type of seizures?
Absence
| Myoclonic
169
Hair loss with regrowth of curly hair is a rare effect of which drug?
Valproate
Phenytoin
Carbamazepine
Lamotrigine
Valproate
170
Taking trimethoprim with phenytoin primarily increases the risk of what?
Hyperkalaemia
Megaloblastic anaemia
Bleeding
Low sodium
Megaloblastic anaemia
Trimethoprim inhibits folate synthesis
Phenytoin increases folate metabolism
(Same with trimethoprim and methotrexate)
171
Purple glove syndrome is a rare side effect of which epilepsy drug?
Phenytoin
172
What is the ideal level range for lithium?
For acute episodes of mania, what would the target level range be?
0. 4–1 mmol/litre -lower end for elderly and for maintenance therapy
0. 8–1 mmol/litre is recommended for acute episodes of mania
173
What is the risk of abrupt lithium withdrawal?
How should it be withdrawn?
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
What is the patient advice regarding diet and fluid intake if on lithium therapy?
Maintain adequate fluid intake and avoid dietary changes which reduce or increase sodium intake.
175
How does lithium interact with ACEis?
Risk of lithium toxicity
Excretion of lithum reduced by ACEi
176
How does lithium interact with NSAIDs?
Risk of lithium toxicity
Excretion of lithium probably reduced by NSAIDs
177
How does lithium interact with loop and thiazide diuretics?
Excretion of lithium reduced by Loop and Thiazide – Sodium depletion
178
How does lithium interact with amiodarone?
Risk of ventricular arrhythmias
179
What is the desired total serum concentration for phenytoin?
What can be a disadvantage of measuring total concentration?
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
Are preparations containing phenytoin sodium and phenytoin base bioequivalent?
No
181
Why is it important to maintain good oral hygiene if taking phenytoin?
Can cause gingival hyperplasia
182
How does phenytoin interact with NSAIDs?
Effect of phenytoin enhanced by NSAIDs
183
How does phenytoin interact with amiodarone?
Amiodarone inhibits metabolism of phenytoin
184
How does phenytoin interact with warfarin?
Phenytoin accelerates metabolism of warfarin
185
How does phenytoin interact with cimetidine?
Cimetidine inhibits the metabolism of phenytoin
186
How does phenytoin interact with fluoxetine?
Phenytoin concentration increased by fluoxetine
187
How does phenytoin interact with St John's Wort?
St. Johns Wort (an enzyme inducer) reduces plasma conc. of phenytoin
188
Is lithium use associated with hyper or hypothyroidism?
Hypothyroidism
189
Which of these side effects is not associated with lithium?
Hyperthyroidism
Tremors
Increased urination/thirst
Leukocytosis
Hyperthyroidism
Associated with hypothyroidism
190
Which of these side effects is not associated with phenytoin?
Skin coarsening
Gum hypertrophy
Hair loss
Osteomalacia
Hair loss
Associated with substantial hair growth (hypertrichosis)
191
Has diazepam got a short or long half life?
Long half life
192
Sinemet absorption is reduced when taken with foods high in what nutrient?
Protein
Fat
Carbohydrates
Protein as it competes with levodopa for absorption
193
Are typical antipsychotics first or second generation antipsychotics?
First generation
194
Are atypical antipsychotics first or second generation antipsychotics?
Second generation
195
What antibiotic class can result in carbamazepine toxicity?
Macrolides
196
What antidepressant can be used for smoking cessation?
Bupropion
197
Carbamazepine commonly causes what electrolyte imbalance?
Hyponatraemia
198
True or false:
| Phenytoin is not known to cause skin pigmentation
False
| Causes yellow-brown pigmentation
199
What is the advice surrounding antipsychotics and sunlight?
As photosensitisation may occur with higher dosages, patients should avoid direct sunlight.
200
What is the general advice regarding monitoring patients on antipsychotics?
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
What is the advice regarding treatment cessation of antipsychotic drugs?
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
What is the NICE 2017 guidance surrounding choice of Donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer's disease?
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
What is ergotamine used for?
In what patient groups would this not be appropriate for?
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
What are the contraindications for benzodiazepines?
Acute pulmonary insufficiency; marked neuromuscular respiratory weakness; sleep apnoea syndrome; unstable myasthenia gravis
205
Selegiline is what type of drug?
Monoamine oxidase B inhibitor
206
What is used as adjunct to co-beneldopa or co-careldopa to reduce 'end of dose' deterioration?
Selegiline - can be used alone
Enatcapone
Tolcapone
207
What parkinsons disease drug colours your urine reddish brown?
Entacapone
208
What Parkinson's Disease medicine can exacerbate oedema and cautioned in congestive heart failure?,
Amantadine
209
Hair loss is a common side effect of what Parkinsons Medicine?
Selegiline
210
How do you manage status epilepticus?
- 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
Treatment with domperidone should not exceed how many days?
7 days
212
Treatment with metoclopramide should not exceed how many days?
5 days
213
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
Inpatient setting is usually 4 weeks
Community setting is usually 12 weeks
214
If a patient is on an opioid withdrawal regime but starts to use illicit drugs again, what should happen?
The withdrawal regimen should be stopped and maintenance therapy should be resumed at the optimal dose.
215
Following successful opioid withdrawal treatment in the management of addiction, how long should the patient be followed up for?
6 months at least
216
True or false:
| For opioid addiction replacement therapy, buprenorphine has to be given every day
False
| Can be given on alternate days in higher doses
217
Does buprenorphine or methadone require a shorter drug-free period (before naltrexone is needed for relapse prevention)?
Buprenorphine
218
Which carries a higher risk of overdose during opioid replacement therapy:
Methadone
Buprenoprhine
Methadone
| Has more severe withdrawal symptoms
219
Which of the following can you titrate faster:
Methadone
Buprenoprhine
Buprenoprhine - can titrate within 1 week
Methadone can take several weeks
220
After how many hours of heroin use can you administer:
Methadone
Buprenoprhine
Why does there need to be a gap?
At least 8 hours after for methadone
6-12 hours after for Buprenoprhine
This is to reduce the risk of precipitated withdrawal
221
What is the recommendation of opioid withdrawal in pregnancy during:
i) 1st trimester
ii) 2nd trimester
iii) 3rd trimester
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
What is the only trimester that you can do opioid withdrawal therapy?
2nd
223
If a patient on methadone becomes pregnant, should they stop the methadone?
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
What do you need to consider in the third trimester in terms of methadone and drug metabolism?
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
What is the advice regarding opioid substitution during breastfeeding?
What red flag symptoms should you look out for?
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
What is lofexidine used for?
Management of symptoms of opioid withdrawal
Can be prescribed as an adjuvant to opioid substitution therapy
227
Smokers who wish to stop smoking should be referred to where?
Their local NHS Stop smoking services
228
What are the most effective drug treatments for smoking cessation?
Varenicline
or
Combination of long acting NRT (patch) AND short acting NRT (gum, lozenge etc)
229
How long are nicotine patches generally applied for?
In what group of patients would this be longer?
16 hours a day, patch removed overnight
24 hours a day is the patient experiences strong nicotine cravings upon waking
230
Can varenicline be used alongside NRT?
No
231
Can varenicline be used alongside bupropion for smoking cessation?
No
232
For smoking cessation, how much treatment should be prescribed for the patient?
2 weeks with an assessment just before their supply finishes
233
Can e-cigarettes be supplied by smoking cessation services?
No
234
When should NRT be used in smoking pregnant patients?
Only if non-drug treatment options have failed
235
What drugs do cigarettes interact with and require higher doses as metabolism is increased?
```
Theophylline
Clozapine
Olanzapine
Haloperidol
Chlorpromazine
Ropinerole
Cinacalcet
```
236
What are the side effects of nicotine containing preparations?
```
Local irritation
GI disturbances
Dry mouth if spray, lozenge
Palpitations - rarely with patches and oral spray
Hot flushes
```
237
Abnormal dreams can occur with which NRT preparation?
Patch- this is reduced if removed before bed
238
Where should you apply an NRT patch?
Do you have to rotate sites of application?
Trunk, upper arm, hip
Yes- Avoid using the same site for several days
239
How long before the target smoking quit date should varenicline and bupropion be started?
7-14 days before
240
Are e-cigs licensed is smoking cessation?
No - aways recommend a licensed treatment if asked e.g. NRT patch
241
A CO level of what suggests the person has stopped smoking or is a non-smoker?
10 ppm or less
242
How long after starting varenicline or bupropion should the person be followed up?
How does this compare with NRT?
3-4 weeks
2 weeks for NRT
243
How many weeks is a course of varenicline?
12 weeks
244
Capsaicin 0.025% cream is licensed for what?
Symptomatic relief in osteoarthritis
245
Using antipsychotics and what drug for dementia can increase the risk of neuroleptic malignant syndrome?
Donepezil
246
What Acetylcholinerase inhibitor is licensed for dementia in Parkinson's Disease (Lewy body)?
Rivastigmine
247
For rivastigmine patches, you should avoid using the same area on the body for how many days?
14 days
248
What are the side effects of cholinergic drugs?
| DUMB BELS
Diarrhoea
Urination
Muscle weakness/cramps
Bronchospasm
Bradycardia
Emesis
Lacrimation (teary eyes)
Salivation/sweating
249
Does lamotrigine have a short or long half life?
Long, allows for OD dosing
250
Does phenytoin have a short or long half life?
Long, allows for OD dosing
251
Does phenobarbital have a short or long half life?
Long, allows for OD dosing
252
Does levetiracetam need to be prescribed by brand?
No - Category 3
253
Does lamotrigine need to be prescribed by brand?
Based on clinical judgement - Category 2
254
Does valproate need to be prescribed by brand?
Based on clinical judgement - Category 2
255
Does ethosuximide need to be prescribed by brand?
No- Category 3
256
Does topimarate need to be prescribed by brand?
Based on clinical judgement - Category 2
257
With antiepileptic carries the risk of cleft palate following exposure in the first trimester?
Topiramate
258
What antiepileptics are present in high amounts in breast milk? (ZELP)
Zonisamide
Ethosuximide
Lamotrigine
Primidone
259
What antiepileptics accumulate in breast feeding children due to a slower metabolism?
Phenobarbital
| Lamotrigine
260
What antiepileptics inhibit sucking reflex in breast feeding?
Phenobarbital
| Primidone
261
What antiepileptics have an established risk of drowsiness in babies?
Benzodiazepines
Phenobarbital
Primidone
262
What antiepileptics carry a high risk of withdrawal symptoms?
Phenobarbital
| Primidone
263
What antiepileptics are mainly associated with antiepileptic hypersensivitiy syndrome?(CP3L)
```
Carbamazepine
Phenytoin
Phenobarbital
Primidone
Lamotrigine
```
In first 8 weeks of starting discontinue immediately
264
What antiepileptics can cause blood dyscrasias?
Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine
Zonisamide
265
What are the signs of phenytoin toxicity? (SNACHD)
```
Slurred speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia
Diplopia
```
266
What pre-treatment screening is needed in Chinese and Thai patients when starting phenytoin and carbamazepine- why?
HLB-B*1502 allele - have an increased risk of Steven-Johnson syndrome
267
True or false:
| Phenytoin inhibits Vitamin D metabolism
False
It induces Vitamin D metabolism- consider supplementation in immobilised patients/inadequate sun exposure or dietary intake of calcium
268
Why is phenytoin cautioned in hepatic impairment?
Decreased protein binding so increased risk of toxicity
269
How does phenytoin and levothyroxine interact?
Phenytoin= enzyme inducer so reduces drug concentration
| Increased risk of hypothyroidism
270
What are the symptoms of carbamazepine toxicity (I HANDBAG)?
In co-cordination
```
Hyponatraemia
Ataxia
Nystagmus
Drowsiness
Blurred vision, diplopia
Arrhythmias
GI disturbances
```
271
If a whole pack of sodium valproate cannot be dispensed, what must be put on the part pack?
Warning sticker
272
If a patient on sodium valproate is experiencing nausea, vomiting, abo pain, what should you do?
Refer
Could be hepatotoxicity or pancreatitis
273
Is lorazepam short or long acting?
Short acting
274
What groups of patients are short acting benzodiazepines more suitable for?
```
Elderly
Hepatic impairment (however in acute alcoholic withdrawal a longer benzodiazepine is used)
```
275
What is a disadvantage of short acting benzodiazepines?
Carries greater risk of withdrawal symptoms
276
Withdrawal symptoms can occur without how much time of stopping a short acting benzodiazepine?
Within 1 day
277
Withdrawal symptoms can occur without how much time of stopping a long acting benzodiazepine?
Within 3 weeks
278
How would you reduce someone's diazepam dose if on long term therapy to prevent withdrawal?
If on high doses, how is this done?
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
279
What schedule is methylphenidate (Concerta)?
CD2
280
What are the side effects of methylphenidate and dexamfetamine?
- 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
281
What is dexamfetamine used for?
Narcolepsy
| Refractory ADHD
282
How would you treat an acute episode of mania?
Benzodiazepines
Antipsychotics- quetiapine, olanzapine, risperidone
Lithium or valproic acid can be added if inadequate response
283
What can you use for prophylaxis of bipolar disorder?
Lithium salts
Sodium valproate / valproic acid
Olanzapine
284
What should you not give in patients with bipolar?
Antidepressants
285
What are the signs of lithium toxicity? (REVNG)
```
Renal disturbances
Extrapyramidal symptoms
Visual disturbances
Nervous system disturbances
GI side effects
```
286
If a patient has persistent headaches and on lithium, what should you do?
Refer
| Lithium can cause benign intracranial hypertension
287
A deficiency in what electrolyte can lead to lithium toxicity?
Sodium (hyponatraemia)
Therefore, be careful if on drugs that cause low sodium e.g. diuretics
288
What is the only antidepressant licensed in children?
Fluoxetine
289
Can SSRIs lower seizure threshold?
Yes
290
Can TCAs cause seizures?
Yes
291
What is the interaction between TCAs and antihypertensives?
Increased risk of hypotension
292
Is moclobemide a reversible or irreversible MAOI?
Reversible - no washout period needed as it is short acting
293
With what MAOIs are hepatotoxicty more likely?
Phenelzine
| Isocarboxazid
294
What is the advice surrounding clozapine and missed doses?
If 2 or more doses missed, then need to re-titrate dose
295
Sexual dysfunction is most common with what antipsychotics?
Haloperidol and risperidone
296
Can antipsychotics interfere with your temperature regulation?
Yes
297
Can antipsychotics cause neuroleptic malignant syndrome?
Yes
298
What are the advantages of using peripheral dopa-decarboxylase inhibitors for Parkinson's?
Lower dose needed for therapeutic effect
Fewer side effects - nausea, vomiting, cardiovascular events
299
What class of drug is pramipexole?
Non ergot derived dopamine agonist
300
What class of drug is ropinerole?
Non ergot derived dopamine agonist
301
What class of drug is rotigotine?
Non ergot derived dopamine agonist
302
What are the side effects of ergot derived dopamine agonists?
Fibrotic reactions
Pulmonary- look out for SOB, cough
Retroperitoneal - look out for abdominal pain and tenderness
Pericardial- look out for cardiac failure
303
Is COMT inhibitor monotherapy licensed in Parkinson's?
No
| Used as an adjunct to levodopa
304
What kind of toxicity is caused by tolcapone?
Hepatotoxicty
| Look out for vomiting, dark urine, abdominal pain
305
What is the antisickness choice of drug in Parkinson's?
Domperidone
306
What two electrolyte imbalances should be corrected before using 5HT3 antagonists e.g. ondansetron?
Hypokalaemia and hypomagnesaemia
307
True or false:
Naloxone only partially reverses the effects of buprenorphine
True
308
In what situations is it advised for patients to immediately remove a fentanyl patch?
Breathing difficulties
Drowsiness, impaired speech
Signs of opioid toxicity
309
Can tramadol lower the seizure threshold?
Yes
310
True or false:
You can take two doses of sumatriptan for the same attack 2 hours later?
True but symptoms must have been improved after taking the first tablet
311
How would you treat trigeminal neuralgia (facial pain with electric shocks in the jaw)?
Carbamazepine or phenytoin
312
Transient insomnia is caused by what?
Shift work
| Jet lag
313
Is zopiclone a long or short acting hypnotic?
Short acting
314
For short term insomnia, hypnotics should not be used for longer than what?
3 weeks max
Ideally 1 week
315
Can methadone cause QT prolongation?
Yes
316
For short term relief of anxiety, hypnotics should not be used for longer than what?
2-4 weeks
317
What are the signs of benzodiazepine withdrawal?
It is characterised by insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances
318
During benzodiazepine withdrawal, what 3 classes of drugs should be avoided if possible (in the case of additional therapy to help with withdrawal symptoms)?
Beta blockers
Antidepressants
Antipsychotics
319
In terms of insomnia, in what cases are short acting hypnotics preferred?
Sleep onset insomnia
Where sedation the following day is not desirable
Elderly
Short term insomnia
320
In terms of insomnia, in what cases are long acting hypnotics preferred?
Poor sleep maintenance e.g. early morning awakening that causes daytime effects
If an anxiolytic effect is needed during the day
Diazepam
321
How should transient insomnia be managed?
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
322
How can chronic insomnia be managed?
What are the common causes of chronic insomnia?
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
323
What is the risk of long term benziodiazepine therapy in the management of insomnia?
Can cause rebound insomnia and a withdrawal syndrome.
324
Is withdrawal more common with short or long acting benzodiazepines?
Short acting
325
Is temazepam long or short acting?
Short acting
326
What would be an appropriate benzodiazepine for someone suffering from insomnia with daytime anxiety?
Diazepam - long acting
| Single dose at night
327
What role do beta blockers play in anxiety?
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
328
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.
True
329
What is 1st line for mild depression if a patient is presenting for the first time?
Psychological therapy should be considered initially
If history of moderate or severe depression, consider antidepressant therapy
330
What class of drug is mirtazapine?
TETRAcycline antidepressant
331
Venlafaxine is generally reserved for what type of depression?
More severe
332
What is classed as chronic anxiety?
>4 weeks duration
333
Is generalised anxiety disorder a form of acute or chronic anxiety?
Chronic
334
What class of drug is duloxetine?
SNRI
335
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?
At least 5 weeks
With other SSRIs, it is only 1 week
336
How long should a patient not drive through after an unprovoked seizure?
6 months
337
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?
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
338
If an epileptic patient has had a seizure whilst asleep, the patient should not drive for 12 months. What are the exceptions?
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
339
Should an epileptic person drive during medication changes?
No
340
If withdrawn from an epilepsy med, how long should a patient not drive for?
6 months
341
What is the MHRA warning associated with the sedating antihistamine hydroxyzine?
QT prolongation
342
What is the therapeutic range for carbamazepine?
4-12 mg/L
343
Has pregabalin got an MHRA warning on the risk of severe respiratory depression?
No - Gabapentin does
344
What is amitriptyline used for?
Major depressive disorder- not recommended
Migraine prophyaxis
Neuropathic pain
345
What would be the starting dose of amitriptyline for neuropathic pain?
10-25mg ON
| Max of 75mg
346
What is pregabalin used for in terms of pain?
Peripheral AND central neuropathic pain
347
What is the max dose of pregabalin a day?
600mg
348
What would be the starting dose of pregabalin for neuropathic pain?
150mg daily in divided doses
349
What is the max dose of gabapentin a day?
3.6g
350
What is gabapentin used for in terms of pain?
Only peripheral neuropathic pain
351
What would be the dosing regimen of gabapentin in neuropathic pain?
Day 1 - 300mg OD
Day 2 - 300mg BD
Day 3 -300mg TDS
