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Chapter 4- NS Flashcards

1
Q

What is dementia

A

Dementia is not a disease it is a progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms such as memory loss problems with reading and communication and a change in personality

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2
Q

What is the most common type of dementia

A

Alzheimer’s disease

Other types include 
Vascular disease (reduced blood flow)
Lewy body 
Mixed dementia
Frontotemporal dementia
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3
Q

What is the aim of treatment of dementia

A

To promote independence maintain function and manage symptoms

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4
Q

Why is minimising the amount of Antimuscarinic drugs a patient with dementia is on be suitable

A

They increase cognitive impairment so it helps management of cognitive symptoms

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5
Q

What is the first line treatment in newly diagnosed patients with mild to moderate Alzheimer’s disease

A

Acetylcholinestrease inhibitors such as donepezil, galantamine or rivastigmine

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6
Q

What is the drug of choice in patients with severe Alzheimer’s disease or when AceE is not tolerated/ contra-indicated

A

Memantine

AChE inhibitors are contraindicated

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7
Q

What medication is indicated for mild to moderate dementia with Lewy bodies

A

AChE inhibitors:
Donepezil or rivastigmine

Then galantamine if those don’t work

Menantamine if acetylcholinestrase inhibitors are not tolerated

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8
Q

When are acetylcholinestrase inhibitors and memantine NOT recommended

A

In patients with frontotempral dementia or cognitive impairment cause by multiple sclerosis

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9
Q

When are antipsychotics indicated for patients with dementia

A

If they are at risk of harming themselves or others if they are experiencing agitation hallucinations or delusions that are causing them severe distress

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10
Q

MHRA ALERT

Why are antipsychotics cautioned in the use of elderly patients with dementia

A

Studies show it has an increased risk of stroke and a small increased risk of death

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11
Q

Name the anticholinesterases that are centrally acting

A

Donepezil
Rivastagmine
Galantamine

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12
Q

Name a dopaminergic NMDA glutamate receptor agonist drug

A

Memantine

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13
Q

What are the symptoms of antiepileptic hypersensitivity syndrome

A

Fever rash and lymphadenopathy are most common

Other symptoms include liver dysfunction, haematological, renal pulmonary abnormalities

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14
Q

Why is monotherapy preferred an epileptic treatment

A

Combination therapy increases the risk of interactions and side-effects

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15
Q

Can epileptic patients drive

A

Yes if they have been seizure free for at least one year
No history of unprovoked seizures
Or if they have only suffered from sleeping seizures for three years

They have a 6 month driving ban if
Medication is being changed or withdrawn and they’ve been seizure free for that time

5 year ban for lorries or vehicles with passengers

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16
Q

Are antiepileptic safe to use in pregnancy

A

Many are teratogenic so advice should be seeked from specialised

In planned pregnancy it is best to stop treatment in the first trimester

In unplanned pregnancy it is best to continue antiepileptic treatment as usual

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17
Q

What anti-epileptic drug has 30-40% chance of severe disorder in pregnancy

A

Sodium valproate

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18
Q

What is the first line treatment for focal (partial) seizures with or without a secondary generalisation

A

Carbamazepine or lamotrigine

Oxcarbazepine, sodium valproate and levetiracetam may be used if the first two fail

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19
Q

What’s the first line treatment for generalised tonic-clonic seizure

A 
Sodium valproate (or carbamazepine)
Lamotrigine is an alternative choice
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20
Q

First line treatment for generalised absence seizures

A

Ethosuximide or Sodium valproate

Lamotrigine is a suitable alternative if they fail

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21
Q

First line treatment for generalised myoclonic seizures

A

Sodium valproate

Topiramate and levetiracetam are options if sodium valproate fails

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22
Q

What signs and symptoms should people on carbamazepine look out for

A

Infection, Blood, liver and skin disorders

Fever rash mouth ulcers bleeding or bruising

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23
Q

What signs and symptoms should patients on lamotrigine look out for

A

Bone marrow failure (anaemia bruising and infection)

Serious skin reaction

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24
Q

What signs and symptoms should patient on valproate as an epileptic look out for

A

Liver toxicity, blood disorder and pancreatitis

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25
Q

What should be routinely monitored when using valllproate

A

Liver function

full blood counts (causes low platelets)

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26
Q

What’s the phenytoin drug level target

And for neonates

A

10-20mg/L (40-80micromol/L)

Neonates: 6-15mg/L

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27
Q

What’s the symptoms of phenytoin toxicity

A

Double vision, slurred speech, ataxia, confusion, hyperglycaemia and nystagmus

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28
Q

What’s important about prescribing phenytoin

A

It’s brand specific so should be prescribed by brand

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29
Q

What a tonic seizures

A

Generalised seizure so affects most the brain. Body becomes stiff/ flexed and you can fall backward

Most often occur during sleep

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30
Q

What is an atonic seizure

A

Generalised seizure with Sudden loss of muscle tone so that the child goes limp and can fall frontwards to the ground

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31
Q

What’s a tonic clonic seizure

A

Generalised seizure that affects the entire brain

Body becomes still, fall backwards followed by aggressive phase

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32
Q

What is a myoclonic seizures

A

Generalised seizure Usually causes abnormal Movements on both sides of the brain at the same time resulting in short muscle twitches

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33
Q

What’s a partial focal seizure

A

Occurs when the electrical activity remains in a limited area of the brain and sometimes turn into generalised seizure which affects the whole brain

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34
Q

Name the category one antiepileptic drugs (CP3)

A

Phenytoin
Carbamazepine
Phenobarbital
Primidone

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35
Q

Name the category two antiepileptic drugs

A 
Valproate 
Lamotrigine 
Perampanel 
Clobazam 
Topiramate 
Zonisamide
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36
Q

Name the category three antiepileptic drugs

A 
Levetiracetam 
Lacosamide 
Tiagabine
Gabapentin 
Vigbatrin
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37
Q

What seizures should you not use pregabalin for

A

Tonic, atonic or absent seizures

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38
Q

What’s the interaction between lamotrigine and valproate

A

Valproate increased lamotrigine concentration

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39
Q

Which antiepileptic is used for only over 18 years

A

Retigabine

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40
Q

Which antiepileptic may be sedative and can develop tolerance

A

Phenobarbital or primidone

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41
Q

Most antiepileptics are given BD which ones have a long half life and I’ll given once a day

A

Lamotrigine
Phenobarbital
Phenytoin
Parampanel

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42
Q

Do younger children metabolise antiepileptics more rapidly or slower

A

More rapidly so higher doses may be needed

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43
Q

What’s the optimise response range levels for carbamazepine

A

4-12mg/L

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44
Q

What are the side-effects does phenytoin have that might affect social life of a person

A

Acne
Gingival hypertrophy

Hypersensitivity reaction (fever, rash)

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45
Q

What side effect is the antiepileptic drug topiramate associated with

A

Myopia with secondary angle-closure glaucoma

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46
Q

What do you do when a patient is having status epilepticus

A

Position patient to avoid injury, support respiration and provide oxygen
Maintain BP, correct hypoglycaemia
Parenteral thiamine given it alcohol abuse suspected
Pyridoxine given it status epilepticus thought to be caused by deficiency
If seizure longer than 5 minutes give IV lorazepam (IV diazepam has risk of thrombophlebitis)
Clonazepam can be an alternative
Phenytoin or fosphenytoin can be given after initial treatment

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47
Q

What are first line antidepressants and why

A

SSRI- they are generally the safest. Less sedating, fewer antimuscarinic and cardio toxic effects

TCA have more pronounced side effects and a more dangerous level of toxicity in overdose

MAOIs have serious interactions with other drugs and some food (can’t have drink, cheese, meat)

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48
Q

Which SSRI is given for anxiety

A

Buspirone

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49
Q

What’s the MHRA alert for the use of benzodiazepines and opioids

A

The use together can produce additive CNS depressant effects increasing the risk of sedation, respiratory depression, coma and death.

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50
Q

If a patient is prescribed benzodiazepines and opioids what should be monitored?

A

Sedation and respiratory depressant effects

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51
Q

What are the hypotonic, sedative and anxiolytic benzodiazepams used for anxiety

(Clue: A D C O)

A

Alprazolam
Chlordiazepoxide
Diazepam
Oxazepam

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52
Q

What is ADHD (attention deficit hyperactivity disorder)

A

Behavioural disorder characterised by hyperactivity, impulsivity and inattention.
Which can lead to functional impairment such as psychological social educational or occupational difficulties.

(Ranges from hyperactive to inattentive)

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53
Q

Aim of treatment for ADHD

A

Reduce functional impairment
Reduce severity of symptoms
Improve quality of life

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54
Q

What are the first line stimulant treatments for patients with ADHD for patients >5 years

A

Centrally acting sympathomimetics

Methylphenidate (first line)
Or
(Lis)Dexamfetamine

For 6 weeks and if no longer improvement try the other one

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55
Q

What should be monitored when CNS stimulants are prescribed for ADHD

A 
Pulse 
Blood pressure 
Appetite 
Weight 
Height 
Psychiatric symptoms

All monitored every 6 months

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56
Q

What schedule are the centrally acting sympathomimetics used for ADHD

A

Schedule 2

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57
Q

When should anti depressants be avoided in patients in bipolar disorder and mania?

A

In patients with rapid cycling bipolar disorder
A recent history of hypomania
Manic episode
Rapid mood fluctuations

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58
Q

Why should benzodiazepines not be used for long periods of time in patients with bipolar disorder and mania?

A

Risk of dependence

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59
Q

When are carbamazepine used in bipolar disorder and mania?

A

In patients unresponsive to a combination of other prophylactic drugs
Used in patients with rapid-cycling manic depressive illness

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60
Q

What is valproate used for in bipolar and mania

A

Valporic acid and sodium valporate are widely used for the treatment of manic episodes associated with bipolar disorder

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61
Q

When is lithium indicated for use in bipolar and mania disorder

A

MOOD STABILISER
Prophylaxis and treatment of mania, hypomania and depression in bipolar disorder and unipolar disorder

Also used for the treatment of aggressive and self harming behaviour

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62
Q

What should you caution with the use of benzo

A

Hepatic impairment as it can lead to coma

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63
Q

How do first generation antipsychotics work

A

They block the dopamine receptor in the brain

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64
Q

Common side effects of first generation antipsychotic

A

EPSE- extra pyramidal side effects

  • Parkinson’s symptoms (such as tremor)
  • Dystonia (abnormal face and body movement)
  • Akathisia (restlessness)
  • Tardative dyskinesia (involuntary movement of the jaw face and tongue)

Raised prolactin (dopamine inhibits prolactin release and antipsychotics block dopamine receptors)

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65
Q

Examples of first generation antipsychotics

A

Chlorpromazine
Haloperidol
Flupentixol

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66
Q

How do Second generation antipsychotics work

A

They act on a range of receptors on the brain

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67
Q

Examples of second generation antipsychotics

A

Aripipazole
Clozapine
Olanzapine
Risperidone

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68
Q

Which group of people should antipsychotics be used with caution

A 
Cardiovascular disease 
Parkinson’s 
Epilepsy 
Depression 
Respiratory disease
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69
Q

What should patients on antipsychotics be told to avoid

A

Sunlight

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70
Q

Which antipsychotic doesnt have hyperprolactinaemia as a side effect and why?

A

Aripiprazole

It’s a partial dopamine receptor agonist while all other antipsychotics are dopamine antagonists
Dopamine inhibits prolactin release

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71
Q

What should be monitored for a patient on antipsychotics

A

FBC, urea, electrolytes, LFTs

Lipid, weight, prolactin, blood pressure, blood glucose

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72
Q

Causation for chlorpromazine dispensing (antipsychotic)

A

Tablets should not be handled

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73
Q

What is clozapine indicated for and what needs to be monitored

A

Schizophrenia

Monitor WBC

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74
Q

Why should lithium be prescribed by brand name

A

It has a narrow therapeutic index and the bioavailability of preparations vary

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75
Q

When can toxic effects present with lithium use

What’s the therapeutic effect

A

Above 1.5 mol/L

0.6-1.2

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76
Q

Why should concurrent use of lithium and diuretics (especially thiazide) be avoided

A

Lithium toxicity is worsened by sodium depletion

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77
Q

What is long term use of lithium linked to

A

Thyroid problems

Should be monitored every 6 months

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78
Q

Why’s it important to prescribe valproate by brand name

A

It includes sodium valproate and valporic acid which have different indications

Valporic acid- mania in bipolar disorder and migraine prophylaxis

Sodium valproate- epilepsy and other types of mania

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79
Q

If the response to antipsychotics is not adequate in acute episodes of mania and hypomania , what can be added

A

Lithium or valproate

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80
Q

Effects of increased prolactin from antipsychotic use

A

Sexual dysfunction
Breast enlargement
Milk production from women (galactorrhoea)

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81
Q

Which anytipsychotics are cautioned in diabetes and why?

A

Clozapine olanzapine Quetiapine and respiridone

Can cause hyperglycaemia

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82
Q

Which antipsychotics can cause weight gain

A

Clozapine and olanzapine

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83
Q

What are the signs of neuroleptic malignant syndrome and what is is causes by

A

Hyperthermia
Muscle rigidity
Sweating
Urinary incontinence

Rare but serious side effect of antipsychotics and donepezil

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84
Q

What is usually the first benefit of antidepressant treatment

A

Improvement of sleep

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85
Q

What treatment should be given for mild depression

A

Psychological therapy

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86
Q

What are the classes of antidepressants

A

Tricyclics (TCA)
Selective serotonin reputable inhibitor (SSRI)
Monoamine oxidase inhibitor (MAOI)

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87
Q

Safest antidepressant for a patient who has had an MI or has unstable angina

A

Sertraline

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88
Q

What is St. John wort

A

A herbal medicine sold for treating mild depression

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89
Q

What is a common side effect of all antidepressant especially SSRI

A

Hyponatraemia

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90
Q

What signs should you look out for in hyponatraemi

A

Drowsiness
Confusion
Convulsion

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91
Q

The 3 major symptoms of serotonin syndrome

A
  1. Neuromuscular hyperactivity (tremor, hyperreflexia, rigidity)
  2. Autonomic dysfunction (tachycardia, BP changes, hyperthermia, shivering)
  3. Altered mental state (agitation, confusion, mania)
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92
Q

Acute anxiety (<4 weeks) is usually managed by benzodiazepines, what can long term anxiety be managed by

A 
Antidepressant (SSRI then SNRI)
Pregabalin can be tried if this fails
Beta blocker 
Barbiturates
Buspirone
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93
Q

After how long of using an antidepressant can it be deemed ineffective

A

4 weeks

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94
Q

How long should antidepressant be carried on for

A

6 months in a otherwise healthy patient

2 years in patients with history of recurrent depression

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95
Q

When should an augmenting agent (lithium, antipsychotic) be added to a depressive treatment

A

If the fail to respond to an SSRI, try increase the dose or another or Mirtazapine (alpha-2 adrenal receptor antagonist)

Failure to respond to that and other classes like SNRI (Venlafaxine) and TCA

Then an augmenting agent may be indicated

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96
Q

Apart from depression what else can SSRI be used for

A

Panic disorder, OCD, social anxiety disorder.

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97
Q

Examples of tricyclics and how they work

A

Amitriptyline
Nortriptyline

Inhibit the re uptake of both serotonin and noradrenaline

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98
Q

What other uses can TCA have other than depression

A

Anxiety and agitation

Neuropathic pain

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99
Q

Common side effects of TCA drugs

A 
Antimuscarinic effects like 
Dry mouth 
Blurred vision 
Urinalysis retention 
Constipation
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100
Q

Drug Interactions with amitriptyline

A

Warfarin- increase or decrease INR

interact with antiepileptic

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101
Q

Examples of SSRI antidepressant

A

Citalopram
Fluoxetine
Paroxetine
Sertraline

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102
Q

What’s the only SSRI effective in people under 18?

A

Fluoxetine

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103
Q

Drug interactions with SSRI

A

Drugs that increase the risk of bleeding
Warfarin
Antiepileptic
Antipsychotics

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104
Q

Duloxetine drug class and when is it indicated?

A

SNRI

Major depression, anxiety, painful diabetic neuropathy, and stress urinalysis incontinence in women

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105
Q

Mirtazapine drug class and how it works

A

Alpha receptor blocker

Increases noradrenaline and serotonin neurotransmission by blocking alpha receptors

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106
Q

Common effects of Mirtazapine

A

Sedation

Weight gain

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107
Q

Name the irreversible MAOI

A

Isocarboxazid
Phenelzine
Tranylcypromide

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108
Q

Examples of SNRI

A

Duloxetine

Venlafaxine

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109
Q

What medication is given for control of deviant antisocial sexual behaviour

A

First generation antipsychotic- benperidol

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110
Q

Which class of antipsychotics are better at treating negative symptoms of schizophrenia

A

Second generation antipsychotics

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111
Q

What’s the MHRA alert for most antipsychotic depot injections

A

The preparation is used for maintenance treatment and should not be used for the rapid control of acute episodes

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112
Q

What is cerebral palsy

A

Permanent, non-progressive abnormalities of the developing fetal or neonatal brain that lead to movement and posture disorders causing activity limitation and functional impact

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113
Q

What is motor neurone disease

A

A neurodegenerative condition affecting the brain and spinal cord

Symptoms include muscle cramps, wasting and stiffness, loss of dexterity, reduced respiratory function and cognitive dysfunction

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114
Q

What drug can be used in essential tremor or to control movement disorder

A

Tetrabenazine

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115
Q

What is Parkinson’s disease

A

A progressive neurogenerative condition resulting from the death of dopaminergic cells of the substantia Nigra in the brain

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116
Q

What are the motor symptoms people with Parkinson’s disease present with

A

Motor symptoms including: hypokinesia, bradykinesia, rigidity, rest tremor and postural instability

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117
Q

What are the non motor symptoms people with Parkinson’s present with

A

Dementia, depression, sleep disturbance, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss

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118
Q

What’s the first line drug treatment of motor symptoms in Parkinson’s disease where QOL is affected

A

Co-careldopa or benserazide

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119
Q

What’s the first line drug treatment of motor symptoms in Parkinson’s disease where QOL is not affected

A

Levodopa (non ergot derived dopamine receptor agonist)
or
monoamine oxidase B inhibitor (eg: rasagiline and selegiline)

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120
Q

What are nonmotor symptoms in Parkinson’s disease

A

Daytime sleepiness and sudden onset of sleep
Postural hypotension
Depression
Psychotic symptoms
Rapid eye movement sleep behaviour disorder
Drooling of saliva
Parkinson’s disease dementia

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121
Q

What is the aim of treatment for Parkinson disease

A

As the disease is not curable the aim is to improve the quality of life of patients with Parkinson’s

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122
Q

When is Parkinson’s drug treatment started

A

When symptoms reach a level where they are causing a significant impact on daily life

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123
Q

Why should Anti-Parkinson drugs be initiated gradually in the elderly

A

Can cause confusion

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124
Q

Give examples of dopamine receptor agonist

A

Pramipexole
Ropinirole
Rotigotine
Apomorphine

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125
Q

What do you levodopa containing drugs interact with

A

MAOIs

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126
Q

How is using MAOBIs with levodopa useful

A

Reduces the ‘end-of-dose’ deterioration experience

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127
Q

How does Entacapone, Opicapone and Tolcapone (COMT inhibitor) work

A

Prevents the peripheral breakdown of levodopa giving it greater opportunity to reach the brain

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128
Q

Common side effect of Entacapone (COMT inhibitors)

A

Can colour the urine a reddish brown colour

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129
Q

What is prolonged levodopa use associated with

A

Weight loss

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130
Q

What can be given to treat nausea and vomiting associated with dopaminergic drugs

A

Domperidone

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131
Q

Why can dopamine agonists be preferred in the long term for younger patients

A

Associated with fewer dyskinesia and motor fluctuations

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132
Q

What negative behavioural symptom are levodopa AND dopamine receptor agonists associated with

A

Compulsive or disinhibited behaviour

Eg: Gambling, hypersexuality, binge eating

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133
Q

How are Antimuscarinic used to help Parkinson’s symptoms

A

Exerts it’s antiparkinsonism action by Reducing the effects of the relative Central Cholinergic excess that occurs as a result of dopamine deficiency

134
Q

Drug classes involved in Parkinson’s drug treatment

A
  • Antimuscarinic (rarely used)
  • Catechol-o-methyltranferase inhibitors
  • Dopamine precursors
  • Dopamine receptor agonist
  • Monoamine Oxidase B inhibitor
135
Q

How do you phenothiazines work (eg: prochlorperazine)

A

They are dopamine antagonist and acts centrally by blocking the chemoreceptor trigger zone

Relieves nausea and vomiting caused by migraines

136
Q

What advantage does domperidone have over metoclopramide and other phenothiazine

A

Less likely to cause central effects such as sedation and dystonic reactions as it doesn’t cross the BBB

137
Q

What is prescribed for meniere disease (ear disease causing a spinning sensation)

A

Betahistine dihydrochloride

138
Q

What can you buy OTC for occasional insomnia

A

Promethazine

139
Q

What antiemetic is mostly used in post operative N&V and chemo

A

Serotonin antagonist (eg: ondansetron)

140
Q

What antiemetic is used for delayed N&V in cisplatin chemo

A

Aprepitant (neurokinin 1 receptor antagonist)

141
Q

What can you give to treat N&V in Parkinson’s caused by dopaminergic drugs

A

Domperidone

142
Q

What’s the advantage of metoclopramide over other phenothiazine

A

It also acts directly on the gastro-intestinal tract so preferred for dmed is associated with gastroduodenal, hepatic and biliary disease

143
Q

Most effective drug for the prevention of motion sickness

A

Hyoscine hydrobromide (Antimuscarinic)

144
Q

Examples of antihistamines used for nausea and vomiting

A

Cyclizine

Promethazine (sedating)

145
Q

When are non-opioid drugs (paracetamol and aspirin) and other NSAIDs particularly suitable

A

Pain in Muscoskeletal conditions

146
Q

When are opioid analgesics suitable

A

Moderate to severe pain particularly with a visceral origin

147
Q

What effect does paracetamol have

A

Analgesic

Antipyretic

148
Q

What’s the best analgesia to use in tooth ache

A

NSAID (ibuprofen, aspirin, diclofenac)

Paracetamol

149
Q

Common side effects of opioid use

A 
Constipation 
Respiratory depression 
Nausea and vomiting 
Drowsiness 
Skin rash
Dry mouth

Dependence

150
Q

What is the most valuable opioid and the standard to which all opioids are compared

A

Morphine

151
Q

What drug reverses opioids action

A

Naloxone

152
Q

How is buprenorphine different to other opioids when it comes to naloxone

A

Naloxone only reverses it’s effects partially

153
Q

Give an example of an opioid with a longer duration of action than morphine

A

Buprenorphine

154
Q

Which opioid has less of the common opioid adverse effects

A

Tramadol

155
Q

What’s the most widely used post operative analgesia

A

Combination of opioid and non-opioid

Morphine
Paracetamol

156
Q

Possible adverse effects of giving opioids epidurally (unlicensed)

A

Pruritis
Urinary retention
Nausea and vomiting
Respiratory depression

157
Q

What strengths do co-codamol come in

A

8/500
15/500
30/500

158
Q

When is codeine contraindicated

A

Children younger than 12

Fast CYP2D6 ultra-rapid metabolisers

Breastfeeding mothers

Acute respiratory depression

Head injury

159
Q

Signs and symptoms of morphine toxicity

A 
Reduced conscienceness 
Lack of appetite 
Somnolence -drowsy
Constipation 
Respiratory depression 
Pin point pupils 
Nausea and vomiting
160
Q

What effect can the variation in codeine metabolism cause

A

Codeine is metabolised into morphine

Ultra rapid codeine metabolisers have a marked increase morphine toxicity

Poor codeine metabolisers have a reduced therapeutic effect

161
Q

What do you give in neuropathic pain

A 
Amitriptyline 
Gabapentin 
Pregabalin 
Tramadol
Corticosteroids
162
Q

What do you give for breakthrough pain

A

Fentanyl or morphine

163
Q

Why should opioids not be used following a head injury

A

They interfere with neurological assessment

164
Q

Why is dipapanone opioid not suitable for palliative care

A

It contains cyclizine

165
Q

Name opioid receptor antagonist and how they work

A

Naloxone and naltrexone

Reverse opioid overdose and precipitate withdrawal symptoms

166
Q

What medication can be used for the treatment of acute migraines

A

Analgesics (paracetamol aspirin)
Serotonin receptors agonist (triptans)
Ergot alkaloids

(Antiemetic if required or a combined analgesic and antiemetic)

167
Q

Why are a ergot alkaloids avoided for migraine

A

Difficulty in absorption and by its side effects

particularly nausea vomiting abdominal pain and muscular cramps

168
Q

When should preventive treatment for migraine be considered

A

For patients who suffer at least two attacks a month

For patients who suffer an increasing frequency of headaches

For patients who suffer significant disability despite suitable treatment for migraine attacks

For patients who cannot take suitable treatment for migraine attacks

169
Q

What medication can you use for prophylaxis of migraine

A 
Beta-blocker (propranolol being the most common)
TCA antidepressant 
Gabapentin 
Sodium valproate/ valporic acid 
Pizotifen
170
Q

What’s the Drug treatment of choice for cluster headache

A

Sumatriptan given intravenously

Oxygen for 10-20 minutes can help with an attack

171
Q

When is the prophylaxis of a cluster headache indicated and what is used

A

It is indicated if the attacks are frequent, if they last over three weeks or if they cannot be treated effectively

Verapamil or lithium are used

172
Q

How is Neuropathic pain managed

A

Tricyclics antidepressants (amitriptyline) or with certain antiepileptic drugs (gabapentin)

173
Q

What can you give a patient with neuropathic pain awaiting review and unable to take oral medication

A

Typical local anaesthetic preparation such as
lidocaine
Or
Capsaicin

174
Q

Why should you avoid the excessive use of acute treatment for migraine

A

It’s associated with medication overuse headache

175
Q

Which non-steroidal anti-inflammatory drug is licensed specifically for acute migraine

A

Tolfenamic acid

176
Q

How long do you have to wait before the dose of a triptan can be repeated

A

Atleast Two hours

177
Q

Why might it be difficult to withdraw hypnotics and anxiolytics

A

Dependence and tolerance occur

178
Q

What’s the most commonly used anxiolytic and hypnotic

A

Benzodiazepines

179
Q

Why are older generation benzodiazepines no used as much as the newer ones

A

They have more adverse effects and interactions

And are more dangerous in overdose

180
Q

When is benzodiazepine indicated in anxiety or insomnia

A

When it’s short term and severe

181
Q

What is transient insomnia

A

Inability to sleep due to other factors like noise shiftwork jetlag etc

182
Q

What is short-term insomnia

A

Inability to sleep due to emotional problems or illness

183
Q

Which benzodiazepine are used as hypnotics normally

A

Nitrazepam
Temazepam

If insomnia is linked with anxiety then diazepam can be used as the hypnotic

184
Q

What are the Z drugs and how do they work

A

Zaleon, zolpidem and Zopiclone

Not benzos but they act on the benzodiazepine receptor

185
Q

What antihistamine can be used for insomnia

A

Promethazine (not recommended)

186
Q

What age group can melatonin be used in to treat insomnia

A

Over 55

187
Q

Why are benzodiazepine preferred over barbiturates in insomnia

A

Less dependence and easier to withdraw

188
Q

What are paracetamol children’s dosing ages 2months - 16 years

A

(NEED TO ADD- Ronans notes)

189
Q

What’s used as substitution in opioid dependence

A

Methadone or buprenorphine

190
Q

What happens if a patient misses atleast 3 days of their opioid maintenance therapy

A

They lose tolerance and are at risk of an overdose

191
Q

Why is methadone the preferred method for opioid dependence over buprenorphine

A

Although buprenorphine is less sedating (as its only a partial agonist) methadone is preferred as it has milder withdrawal symptoms

192
Q

What do severe cases of alcohol withdrawal include

A

Seizures
Delirium
Death

193
Q

What medications are commonly used to control alcohol withdrawal

A

Chlordiazepoxide (a long acting benzo)
Carbamazepine (if benzo not appropriate)

Antipsychotic may be added to control delirium

194
Q

What are recovering alcoholics given to prevent relapse

A

Acamprosate or naltrexone

195
Q

What are alcoholics given to reduce their risks of developing encephalopathy

A 
Parental thiamine (pabrinex)
Followed by oral thiamine
196
Q

What can hepatitis associated with alcohol intake be treated with

A

Corticosteroids

197
Q

What should be offered to patients trying to quit smoking

A

Nicotine replacement therapy in many forms

Varenicline- selective nicotine receptor partial agonist

198
Q

What should be monitored with varenicline and when should it be stopped

A

Psychiatric performance

Stop if suicide ideation or depressed moods occur

199
Q

What are common examples of drugs that when a patient stops smoking the dose need to be reduced (as smoking increases the metabolism)

A

Theophylline
Ropinirole
Some antipsychotics

200
Q

How long would it take for untreated heroin dependence symptoms to show

A

8 hours

Can subside after 5 days

201
Q

What is methadone lintus licensed for

A

As an analgesia in severe pain-and cough in terminal disease

202
Q

Why should Bupropion for smoking cessation not be used in epilepsy

A

Lowers seizure threshold

203
Q

Why should donepezil be taken in the morning

A

Vivid dreams have been reported

204
Q

Why do people on clozapine need to take regular blood tests

A

It causes a severe deficiency in neutrophils (agranulocytosis)

205
Q

When are benzodiazepam commonly indicated

A

First-line management of seizures and status Epilepticus
Personal management of alcohol withdrawal reactions
Common choice of sedation for interventional procedures
Short-term treatment of severe anxiety or insomnia

206
Q

What are common cholinergic (para sympathomimetics) side effects

Clue: D U M B B E L S

A 
Diahhroa 
Urination 
Muscle weakness, cramps 
Bronchospasm 
Bradycardia 
Emesis (vomiting)
Lactimation (teary eyes)
Salivation/ sweating
207
Q

What is the MHRA alert regarding antiepileptic drug switching

List the 3 catergories and the drugs in them

A

Potential harm when switching between different manufacturer products for a particular drug

Catergory 1: maintain the same product (CP3)
Carbamazepine, phenytoin, phenobarbital, primidone

Catergory 2: clinical judgment
Valproate, lamotrigine, clonazepam, topiramate

Catergory 3: don’t need to maintain the same product

208
Q

What’s the caution of taking carbamazepine with contraception?

A

It reduces the efficacy of hormonal contraception

209
Q

Which anti epileptic drugs are present in high amounts in milk (clue: Z E L P)

A

Zosinanide
Ethosuximide
Lamotrigine
Primidone

210
Q

What’s the MHRA alert regarding Gabapentin

A

Risk of severe respiratory depression

211
Q

How does phenytoin work

A

It binds to neuronal sodium channels in their inactive state to prolong activity

212
Q

Signs and symptoms of phenytoin drug toxicity (clue: S N A C H D)

A 
Slurred speech 
Nystagmus (uncalled eye movement)
Ataxia (uncontrolled muscle movement)
Confusion 
Hyperglycaemia 
Diplopia (double vision, blurred vision)
213
Q

How does carbamazepine work

A

It inhibits neuronal sodium channels, stabilises membrane potential and reduced neuronal exciteability

214
Q

Signs and symptoms of carbamazepine toxicity (clue: I handbag)

A 
Inco-ordination 
Hyponatraemia
Ataxia (involuntarily muscle movement)
Nystamus (involuntary eye movement)
Drowsiness 
Blurred vision 
Arrhythmia 
GI disturbances
215
Q

What’s status epilepticus and what’s the treatment

A

Epileptic fits follow one after the other without regaining consciousness (>5 minutes)

IV lorazepam (not diazepam as can cause thrombophlebitis)

216
Q

How does methylphenidate and Dexamfetamine work, it’s drug schedule and what’s it used for

A

It’s a potent CNS stimulant it increases dopamine and noradrenaline levels in the brain

Schedule 2 CD

Used as first like in ADHD

217
Q

What’s used in acute episodes of mania and hypo mania

A

Benzodiazepines
Antipsychotics (QOR)- quetiapine, olanzapine, risperidone
(Lithium or valporic acid added if antipsychotic alone is not adequate)

218
Q

What’s used in the prophylaxis of bipolar disorder

A

Lithium salts
Valproate
Olanzapine

219
Q

What’s the therapeutic range for lithium

A

0.4mmol- 1mmol/L

220
Q

Signs and symptoms or lithium toxicity (clue: R E V N G)

A 
Renal disturbances (excessive urination)
Extrapyrimidal symptoms 
Visual disturbances 
Nervous system disturbances 
Gastro intestinal disturbances (vomiting and diarrhoea)
221
Q

Side effects of lithium

A 
Thyroid disorders 
Renal impairment 
Hypertension 
QT prolongation 
Lowers seizure threshold
222
Q

What’s the only antidepressant safe to use on children

A

Fluoxetine

223
Q

What antidepressant prolong QT INTERVAL

A

Citalopram and Escitalopram

224
Q

What’s less sedating, less Antimuscarinic and less cardio toxic, TCA or SSRI

A

SSRI

225
Q

Why does metoclopramide have a maximum 5 day use?

A

MHRA ALERT
It has a risk of neurological adverse effects

(EPSE due to crossing the BBB)

226
Q

Why does domperidone have a maximum use of 1 week?

A

MHRA ALERT

Risk of cardiac side effects

227
Q

Opioid side effects (clue morphine)

A 
Miosis (pin point pupils)
Out of it (sedation)
Respiratory depression 
Postural hypotension 
Hallucinations 
Infrequency (urinary, constipation)
Nausea and vomiting 
Euphoria
228
Q

Why should codeine and dihydrocodeine never be given via the IV route?

A

Severe reaction similar to anaphylaxis

CD2 when given the IM route

229
Q

Why’s codeine not given to children under 12

A

Can cause breathing problems

The metabolism into morphine is unknown

230
Q

What drugs lower seizure threshold

A

Tramadol
TCA
SSRI

231
Q

What’s used for anxiety

A

Benzodiazepines
Barbiturates
Buspirone

232
Q

Of the meds used for anxiety, which ones not a sedative

A

Buspirone

233
Q

What do you monitor with phenobarbital

A

CLUE: LOW AND SLOW

Low respiratory
Low blood pressure
Sedation

234
Q

In terms of the patients bloods, when is giving lithium contraindicated

A

Hyponatraemia

Dehydration

235
Q

What needs to be counselled for a patient starting carbemazipine and on oral contraception?

A

Oral contraceptives not effective will need alternative birth control method

236
Q

What’s an important possible adverse effect of donepezil

A

Neuroleptic malignant syndrome

237
Q

Which side effect should galantamine be stopped immediately

A

First appearance of a skin rash

Risk of SJS

238
Q

What is important to note with contraception and antiepileptic

A

Enzyme inducing antiepileptics (eg: carbamazepine) reduce the efficiency of hormonal contraception

239
Q

Which antiepileptic are present in high amounts in breast feeding milk (clue ZELP)

A

Zosinamide
Ethosuximide
Lamotrigine
Primidone

240
Q

What would you give for a convulsive status epilepticus?

A

IV lorazepam

Avoid IV diazepam as it causes thrombophlebitis

241
Q

What’s the MHRA alert for the nsaid piroxicam

A

Should not exceed 20mg OD

242
Q

Which NSAID is best to give to a patient with high CV risk

A

Ibuprofen <1.2g daily

Naproxen <1g

243
Q

Which drugs can cause Parkinsonism symptoms

A 
Cinnarizine
Flunarozine
Pet hiding
Sodium valproate 
Amiodarone 
Metoclopramide
244
Q

Why should Z drugs and benzodiazepines be avoided in elderly

A

Ataxia and confusion = falls/ injury

245
Q

What vitamin deficiency can excess alcohol cause

A

Vitamin B1 (thiamine)

246
Q

What needs to be monitored with methylphenidate for ADHD and why

A

Weight and height

As it can affect the growth of some children

247
Q

Which antidepressant drug can increase the risk of bleeding

A

Sertraline

248
Q

How many weeks can it take for buspirone to work

A

Up to 2 weeks

249
Q

What’s the wash out period for the different anti depressants

A

MOAI wait 2 weeks

SSRI wait 1 week

TCA wait 1-2 weeks (3 weeks if imipramine or clomipramine)

250
Q

How long does it take for buspirone to work

A

2 weeks

251
Q

Common adverse effect of pizotifen (used for headaches)

A

Weight gain

252
Q

Which antiepileptic carried an increased risk of cleft palates if taken in the first trimester or pregnant

A

Topiramate

253
Q

Lithium and ACEi interaction

A

ACEi increased the concentration of lithium

254
Q

What needs to be monitored and how often with lithium

A

BMI
Serum electrolytes
Renal function
Thyroid function

Every 6 months

255
Q

What do you give for Alzheimer’s disease for a patient with Parkinson’s disease

A

Rivastagmine

256
Q

What’s given for non cognitive symptoms of dementia including extreme violence, aggression and extreme behaviour

A

Oral benzodiazepines
Or
Antipsychotics

(If IM needed lorazepam, halopiredol, olanzapine)

257
Q

Most antiepileptics are BD dosing, name the OD ones

A

Lamotrigine
Perampanel
Phenytoin

258
Q

Which antiepileptic require you to monitor foetal growth

A

Topiramate

Levetiracetam

259
Q

What’s advices for women to take when they become pregnant and on anti epileptics

A

5mg folic acid until 12 weeks

260
Q

Which antiepileptic can inhibit sucking reflex in babies

A

Phenobarbitals and primidone

261
Q

What’s febrile convulsions and what’s used for it

A

Seizures that occur when a child has a high fever

Paracetamol (antipyretic)
If >5 minutes treat as a status epilepticus (IV lorazepam)

262
Q

Psychological symptoms of anxiety

A 
Restlessness 
Worry 
Fear 
Difficulty swallowing 
Irritability
263
Q

Physical symptoms of anxiety

A 
Palpitations 
Muscle aches and tension 
Trembling and shaking 
Excessive sweating 
SOB 
Insomnia
264
Q

Whens lithium blood samples taken

A

12 hours after dose

265
Q

Counselling for diet on lithium

A

Don’t have significant changes to your diet especially sodium

266
Q

Which antidepressants have a higher risk of withdrawal reactions

A

Paroxetine

Venlafaxine

267
Q

MHRA alert for clozapine

A

GI obstruction

268
Q

What’s used in advanced Parkinson disease

A

Apomorphine

269
Q

What strength of morphine oral solution counts as a CD5

A

13mg/5ml or less

270
Q

The first line parenteral route for opioids

A

Diamorphine (heroin)

271
Q

What’s the equivalent diamorphine dose to morphine

A

1/3 of the morphine dose

272
Q

What should you counsel with patch medications

A

Avoid exposure to external heat (eg: sauna) as it results in increased absorption

And rotate patch site

273
Q

What’s the MHRA advice for codeine use in 12-18 year olds

A

Max 240mg a day for 3 days

274
Q

Which opioid also affect the noradrenaline and serotonin uptake

A

Tramadol

275
Q

What interactions does tramadol have

A

It lowers seizure threshold

Bleeding risk (warfarin)

Serotonin syndrome

276
Q

What can you use for conscious sedation of dental procedures

A

Temazepam

277
Q

Which SSRI has a long half life

A

Fluoxetine

278
Q

Epilepsy treatment options in kids

A

Sodium valproate
Leveretacium
Topiramate

279
Q

Is routine plasma concentration required for lithium and sodium valproate

A

No

280
Q

Interactions with lithium

A

ACEi - lithium toxicity
NSAIDs- lithium toxicity
Diuretics- hyponatraemia
Amiodarone- risk of arrhythmia

281
Q

What should be counselled when giving disulfiram (treatment of alcohol dependence)

A

Alcohol should be avoided atleast 1 week after therapy has stopped

Patients should not ingest alcohol at all as there a serious interaction

282
Q

Can you breast feed while on anti epileptics drugs

A

Yes safe with nearly all of them

283
Q

Is opioid analgesic safe to use in pregnancy

A

Contraindicated in the 3rd trimester as it can depress neonatal respiration

284
Q

How can you treat neuroleptic malignant syndrome

A

Dopamine receptor agonist

Bromocriptine or Dantrolene

285
Q

Why would you caution metoclopramide in female adolescents

A

Extrapyramidal side effect

286
Q

What’s preferred for motion sickness when the journeys long

A

Old generation antihistamines as they have a long mode of action

287
Q

Why should patients be adviced to take migraine meds straight away on an onset of an attack

A

When migraine occurs gastric emptying slows down so absorption is reduced

288
Q

When do you refer for a migraine?

A

Symptoms occurring for the first time
Migraine in a child
Medication not relieving symptoms
First migraine occurred after the age of 40

289
Q

What medications are sold otc for insomnia

A

Diphenhydramine (treatment of choice) and promethazine

290
Q

What is epilepsy

A

A disorder of the brain characterised by:

Atleast 2 unprovoked seizures occurring more that 24 hours apart

One unprovoked seizure and a probability of further seizures

291
Q

Which dementia is drug treatment not recommended for

A

Vascular dementia

And with the others should only be continued if there’s behavioural or cognitive benefit

292
Q

What can be given to minimise neonatal haemorrhage in newborns where the mother was taking anti epileptic medication

A

Vitamin K injection

293
Q

Which medication can cause the most withdrawal effects from the mother taking them in newborns

A

Benzodiazepine

Phenobarbital

294
Q

What should all breastfed infants where the mothers taking antiepileptic medications be monitored for

A 
Drowsiness 
Weight gain 
Feeding difficulty 
Adverse effects 
Developmental milestones
295
Q

What has MHRA reported with all antiepileptic drugs

A

Increased with of suicidal behaviour and thoughts and

296
Q

Which antiepileptic medication cause blood dyscrasias and should report signs of infections

A

‘C vet pls’

Carbamazepine 
Valproate 
Ethosuximide
Topiramate
Phenytoin
Lamotrigine 
Zonisamide
297
Q

What antiepileptic medication can cause eye problems

A

Vigabatrin (visual symptoms)

Topiramate (raised intra ocular pressure)

298
Q

Name a few CNS depressants

A 
Benzodiazepines 
Opioids 
Hypnotics 
Barbiturates 
Antipsychotics 
Lithium 
Antidepressants 
Alcohol 
Antiepileptic
299
Q

Side effects of phenytoin

A 
Change in appearance (rash)
Blood dycrasias 
Hypersensitivity reaction 
Rashes (chinese and Thai patients with HLAV*1502 allele are at risk of Sjs)
Low vitamin d- osteomalacia and rickets 
Hepatotoxicity 
Suicidal ideation

Iv route- bradycardia and hypotension

300
Q

Side effects of carbamazepine

A 
Blood dyscrasias 
Hepatotoxicity 
Hypersensitivity reaction 
Rashes (chinese and Thai patients with HLAV*1502 allele are at risk of Sjs)
Hyponatraemia
301
Q

What’s the conditions of PPP for valproate supply

A

7 day prescription
30 day supply
Use highly effective contraception
Exclude pregnancy before treatment

Fully informed of the risk of use in pregnancy and sign a form

302
Q

What do the nations of the pharmacist include everytime they dispense valproate

A

Remind of risk of pregnancy and need for contraception
Remind of need for annual specialist review
Dispense as whole patch when possible
Provide valproate patient card
Provide patient guide

Refer patient to GP if not taking contraception

303
Q

Side effects of valproate

A

Hepatotoxicity (fatal)
Blood dysrasias
Pancreatitis

Monitor: liver function test and full blood count

304
Q

How would you withdraw diazepam

A

Gradually convert to equivalent diazepam dose ON over 1 week

Reduce diazepam dose by 1-2mg increments every 2-4 weeks

Reduce diazepam dose further- can reduce in smaller steps of 500mcg towards the end

305
Q

What should the withdrawal period be for antipsychotics

A

4 weeks of still being treated with other anti manic meds

3 months of completely stopping

306
Q

How long should prophylactic treatment of bipolar disorder be continued

A

2 years from last manic episode

5 years if experienced a relapse

307
Q

What concentration are you likely to experience toxic effects with lithium

A

2mmol/ L

308
Q

Which antidepressant doesn’t require a washout period

A

Moclobemide

Due to the short acting/ reversible action

309
Q

What’s the washout period for fluoxetine

A

5 weeks

310
Q

What determines the choice of antipsychotic

A

Group 1 more sedative and more EPSE so if has Parkinson’s and if not wanted group 2 chosen

Group 2 more metabolic side effects so if overweight or has diabetes group 1 chosen

Level of sedation required also determines choice

311
Q

How long should you give to assess clozapine response

A

8-10 weeks

312
Q

How many missed doses of clozapine till it needs to be referred to specialist

A

2 or more missed doses

313
Q

Side effect of the antipsychotic pimozide

A

Qt prolongation, cases of sudden death

314
Q

What does selegiline metabolise to

A

Amphetamine

315
Q

What should be added to parkinsons id dyskinesia is not adequately managed by modifying therapy

A

Amantadine

316
Q

What’s reserved advanced Parkinson’s disease and what’s the use

A

Apormorphine

Used in motor fluctuations in the off period

317
Q

What’s the use of carbidopa and beserazide

A

To get more levodopa into the brain with a smaller dose

Transporter

318
Q

Whys it important to take levodopa at a specific time each day

A

To avoid off periods

319
Q

Why are Ergot derived medication not used in Parkinson disease

A

Side effect of fibrotic reactions

320
Q

Why’s entacapone preferred over tolcapone

A

Tolcapone can cause loose threatening hepatotoxicity

321
Q

What’s break through pain?

A

Sudden flare of Pain that breaks through regular medication

322
Q

What’s the doses of rescue dose

A

Min 1/10th
Max 1/6th

Of the total dose of strong opioid every 2-4 hours PRN

323
Q

Cautionary and advisory labels on opioids

A

Warning. This medication may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol

324
Q

What increments can morphine be increased

A

1/3 or 1/2 total daily dose per 24hours

325
Q

What parental dose is equivalent to an oral dose

A

Parental dose is equivalent to half the oral dose

326
Q

What’s the equivalent dose of diamorphine to oral morphine

A

Diamoprhine is equivalent to 1/3 of oral morphine

327
Q

How long can buprenorphine patches last

Fentanyl?

A

3, 4 or 7 days

Fentanyl- 3 days

328
Q

What can be used to treat daytime symptoms in Parkinson’s patients

A

Modafinil

329
Q

Why does carbamazepine have a higher maintenance dose than losing dose

A

It is an enzyme auto inducer

So it induces its own metabolism so maintenance dose is higher than the initial dose

330
Q

What’s the interaction between sumatriptan and tramadol

A

Both increase the risk of serotonin syndrome

331
Q

Which antiemetics are less teratogenic

A

Lamotrigine and levetiracetam

Pre-reg (27 decks)

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