Chapter 4- NS Flashcards
What is dementia
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
What is the most common type of dementia
Alzheimer’s disease
Other types include Vascular disease (reduced blood flow) Lewy body Mixed dementia Frontotemporal dementia
What is the aim of treatment of dementia
To promote independence maintain function and manage symptoms
Why is minimising the amount of Antimuscarinic drugs a patient with dementia is on be suitable
They increase cognitive impairment so it helps management of cognitive symptoms
What is the first line treatment in newly diagnosed patients with mild to moderate Alzheimer’s disease
Acetylcholinestrease inhibitors such as donepezil, galantamine or rivastigmine
What is the drug of choice in patients with severe Alzheimer’s disease or when AceE is not tolerated/ contra-indicated
Memantine
AChE inhibitors are contraindicated
What medication is indicated for mild to moderate dementia with Lewy bodies
AChE inhibitors:
Donepezil or rivastigmine
Then galantamine if those don’t work
Menantamine if acetylcholinestrase inhibitors are not tolerated
When are acetylcholinestrase inhibitors and memantine NOT recommended
In patients with frontotempral dementia or cognitive impairment cause by multiple sclerosis
When are antipsychotics indicated for patients with dementia
If they are at risk of harming themselves or others if they are experiencing agitation hallucinations or delusions that are causing them severe distress
MHRA ALERT
Why are antipsychotics cautioned in the use of elderly patients with dementia
Studies show it has an increased risk of stroke and a small increased risk of death
Name the anticholinesterases that are centrally acting
Donepezil
Rivastagmine
Galantamine
Name a dopaminergic NMDA glutamate receptor agonist drug
Memantine
What are the symptoms of antiepileptic hypersensitivity syndrome
Fever rash and lymphadenopathy are most common
Other symptoms include liver dysfunction, haematological, renal pulmonary abnormalities
Why is monotherapy preferred an epileptic treatment
Combination therapy increases the risk of interactions and side-effects
Can epileptic patients drive
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
Are antiepileptic safe to use in pregnancy
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
What anti-epileptic drug has 30-40% chance of severe disorder in pregnancy
Sodium valproate
What is the first line treatment for focal (partial) seizures with or without a secondary generalisation
Carbamazepine or lamotrigine
Oxcarbazepine, sodium valproate and levetiracetam may be used if the first two fail
What’s the first line treatment for generalised tonic-clonic seizure
Sodium valproate (or carbamazepine) Lamotrigine is an alternative choice
First line treatment for generalised absence seizures
Ethosuximide or Sodium valproate
Lamotrigine is a suitable alternative if they fail
First line treatment for generalised myoclonic seizures
Sodium valproate
Topiramate and levetiracetam are options if sodium valproate fails
What signs and symptoms should people on carbamazepine look out for
Infection, Blood, liver and skin disorders
Fever rash mouth ulcers bleeding or bruising
What signs and symptoms should patients on lamotrigine look out for
Bone marrow failure (anaemia bruising and infection)
Serious skin reaction
What signs and symptoms should patient on valproate as an epileptic look out for
Liver toxicity, blood disorder and pancreatitis
What should be routinely monitored when using valllproate
Liver function
full blood counts (causes low platelets)
What’s the phenytoin drug level target
And for neonates
10-20mg/L (40-80micromol/L)
Neonates: 6-15mg/L
What’s the symptoms of phenytoin toxicity
Double vision, slurred speech, ataxia, confusion, hyperglycaemia and nystagmus
What’s important about prescribing phenytoin
It’s brand specific so should be prescribed by brand
What a tonic seizures
Generalised seizure so affects most the brain. Body becomes stiff/ flexed and you can fall backward
Most often occur during sleep
What is an atonic seizure
Generalised seizure with Sudden loss of muscle tone so that the child goes limp and can fall frontwards to the ground
What’s a tonic clonic seizure
Generalised seizure that affects the entire brain
Body becomes still, fall backwards followed by aggressive phase
What is a myoclonic seizures
Generalised seizure Usually causes abnormal Movements on both sides of the brain at the same time resulting in short muscle twitches
What’s a partial focal seizure
Occurs when the electrical activity remains in a limited area of the brain and sometimes turn into generalised seizure which affects the whole brain
Name the category one antiepileptic drugs (CP3)
Phenytoin
Carbamazepine
Phenobarbital
Primidone
Name the category two antiepileptic drugs
Valproate Lamotrigine Perampanel Clobazam Topiramate Zonisamide
Name the category three antiepileptic drugs
Levetiracetam Lacosamide Tiagabine Gabapentin Vigbatrin
What seizures should you not use pregabalin for
Tonic, atonic or absent seizures
What’s the interaction between lamotrigine and valproate
Valproate increased lamotrigine concentration
Which antiepileptic is used for only over 18 years
Retigabine
Which antiepileptic may be sedative and can develop tolerance
Phenobarbital or primidone
Most antiepileptics are given BD which ones have a long half life and I’ll given once a day
Lamotrigine
Phenobarbital
Phenytoin
Parampanel
Do younger children metabolise antiepileptics more rapidly or slower
More rapidly so higher doses may be needed
What’s the optimise response range levels for carbamazepine
4-12mg/L
What are the side-effects does phenytoin have that might affect social life of a person
Acne
Gingival hypertrophy
Hypersensitivity reaction (fever, rash)
What side effect is the antiepileptic drug topiramate associated with
Myopia with secondary angle-closure glaucoma
What do you do when a patient is having status epilepticus
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
What are first line antidepressants and why
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)
Which SSRI is given for anxiety
Buspirone
What’s the MHRA alert for the use of benzodiazepines and opioids
The use together can produce additive CNS depressant effects increasing the risk of sedation, respiratory depression, coma and death.
If a patient is prescribed benzodiazepines and opioids what should be monitored?
Sedation and respiratory depressant effects
What are the hypotonic, sedative and anxiolytic benzodiazepams used for anxiety
(Clue: A D C O)
Alprazolam
Chlordiazepoxide
Diazepam
Oxazepam
What is ADHD (attention deficit hyperactivity disorder)
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)
Aim of treatment for ADHD
Reduce functional impairment
Reduce severity of symptoms
Improve quality of life
What are the first line stimulant treatments for patients with ADHD for patients >5 years
Centrally acting sympathomimetics
Methylphenidate (first line)
Or
(Lis)Dexamfetamine
For 6 weeks and if no longer improvement try the other one
What should be monitored when CNS stimulants are prescribed for ADHD
Pulse Blood pressure Appetite Weight Height Psychiatric symptoms
All monitored every 6 months
What schedule are the centrally acting sympathomimetics used for ADHD
Schedule 2
When should anti depressants be avoided in patients in bipolar disorder and mania?
In patients with rapid cycling bipolar disorder
A recent history of hypomania
Manic episode
Rapid mood fluctuations
Why should benzodiazepines not be used for long periods of time in patients with bipolar disorder and mania?
Risk of dependence
When are carbamazepine used in bipolar disorder and mania?
In patients unresponsive to a combination of other prophylactic drugs
Used in patients with rapid-cycling manic depressive illness
What is valproate used for in bipolar and mania
Valporic acid and sodium valporate are widely used for the treatment of manic episodes associated with bipolar disorder
When is lithium indicated for use in bipolar and mania disorder
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
What should you caution with the use of benzo
Hepatic impairment as it can lead to coma
How do first generation antipsychotics work
They block the dopamine receptor in the brain
Common side effects of first generation antipsychotic
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)
Examples of first generation antipsychotics
Chlorpromazine
Haloperidol
Flupentixol
How do Second generation antipsychotics work
They act on a range of receptors on the brain
Examples of second generation antipsychotics
Aripipazole
Clozapine
Olanzapine
Risperidone
Which group of people should antipsychotics be used with caution
Cardiovascular disease Parkinson’s Epilepsy Depression Respiratory disease
What should patients on antipsychotics be told to avoid
Sunlight
Which antipsychotic doesnt have hyperprolactinaemia as a side effect and why?
Aripiprazole
It’s a partial dopamine receptor agonist while all other antipsychotics are dopamine antagonists
Dopamine inhibits prolactin release
What should be monitored for a patient on antipsychotics
FBC, urea, electrolytes, LFTs
Lipid, weight, prolactin, blood pressure, blood glucose
Causation for chlorpromazine dispensing (antipsychotic)
Tablets should not be handled
What is clozapine indicated for and what needs to be monitored
Schizophrenia
Monitor WBC
Why should lithium be prescribed by brand name
It has a narrow therapeutic index and the bioavailability of preparations vary
When can toxic effects present with lithium use
What’s the therapeutic effect
Above 1.5 mol/L
0.6-1.2
Why should concurrent use of lithium and diuretics (especially thiazide) be avoided
Lithium toxicity is worsened by sodium depletion
What is long term use of lithium linked to
Thyroid problems
Should be monitored every 6 months
Why’s it important to prescribe valproate by brand name
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
If the response to antipsychotics is not adequate in acute episodes of mania and hypomania , what can be added
Lithium or valproate
Effects of increased prolactin from antipsychotic use
Sexual dysfunction
Breast enlargement
Milk production from women (galactorrhoea)
Which anytipsychotics are cautioned in diabetes and why?
Clozapine olanzapine Quetiapine and respiridone
Can cause hyperglycaemia
Which antipsychotics can cause weight gain
Clozapine and olanzapine
What are the signs of neuroleptic malignant syndrome and what is is causes by
Hyperthermia
Muscle rigidity
Sweating
Urinary incontinence
Rare but serious side effect of antipsychotics and donepezil
What is usually the first benefit of antidepressant treatment
Improvement of sleep
What treatment should be given for mild depression
Psychological therapy
What are the classes of antidepressants
Tricyclics (TCA)
Selective serotonin reputable inhibitor (SSRI)
Monoamine oxidase inhibitor (MAOI)
Safest antidepressant for a patient who has had an MI or has unstable angina
Sertraline
What is St. John wort
A herbal medicine sold for treating mild depression
What is a common side effect of all antidepressant especially SSRI
Hyponatraemia
What signs should you look out for in hyponatraemi
Drowsiness
Confusion
Convulsion
The 3 major symptoms of serotonin syndrome
- Neuromuscular hyperactivity (tremor, hyperreflexia, rigidity)
- Autonomic dysfunction (tachycardia, BP changes, hyperthermia, shivering)
- Altered mental state (agitation, confusion, mania)
Acute anxiety (<4 weeks) is usually managed by benzodiazepines, what can long term anxiety be managed by
Antidepressant (SSRI then SNRI) Pregabalin can be tried if this fails Beta blocker Barbiturates Buspirone
After how long of using an antidepressant can it be deemed ineffective
4 weeks
How long should antidepressant be carried on for
6 months in a otherwise healthy patient
2 years in patients with history of recurrent depression
When should an augmenting agent (lithium, antipsychotic) be added to a depressive treatment
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
Apart from depression what else can SSRI be used for
Panic disorder, OCD, social anxiety disorder.
Examples of tricyclics and how they work
Amitriptyline
Nortriptyline
Inhibit the re uptake of both serotonin and noradrenaline
What other uses can TCA have other than depression
Anxiety and agitation
Neuropathic pain
Common side effects of TCA drugs
Antimuscarinic effects like Dry mouth Blurred vision Urinalysis retention Constipation
Drug Interactions with amitriptyline
Warfarin- increase or decrease INR
interact with antiepileptic
Examples of SSRI antidepressant
Citalopram
Fluoxetine
Paroxetine
Sertraline
What’s the only SSRI effective in people under 18?
Fluoxetine
Drug interactions with SSRI
Drugs that increase the risk of bleeding
Warfarin
Antiepileptic
Antipsychotics
Duloxetine drug class and when is it indicated?
SNRI
Major depression, anxiety, painful diabetic neuropathy, and stress urinalysis incontinence in women
Mirtazapine drug class and how it works
Alpha receptor blocker
Increases noradrenaline and serotonin neurotransmission by blocking alpha receptors
Common effects of Mirtazapine
Sedation
Weight gain
Name the irreversible MAOI
Isocarboxazid
Phenelzine
Tranylcypromide
Examples of SNRI
Duloxetine
Venlafaxine
What medication is given for control of deviant antisocial sexual behaviour
First generation antipsychotic- benperidol
Which class of antipsychotics are better at treating negative symptoms of schizophrenia
Second generation antipsychotics
What’s the MHRA alert for most antipsychotic depot injections
The preparation is used for maintenance treatment and should not be used for the rapid control of acute episodes
What is cerebral palsy
Permanent, non-progressive abnormalities of the developing fetal or neonatal brain that lead to movement and posture disorders causing activity limitation and functional impact
What is motor neurone disease
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
What drug can be used in essential tremor or to control movement disorder
Tetrabenazine
What is Parkinson’s disease
A progressive neurogenerative condition resulting from the death of dopaminergic cells of the substantia Nigra in the brain
What are the motor symptoms people with Parkinson’s disease present with
Motor symptoms including: hypokinesia, bradykinesia, rigidity, rest tremor and postural instability
What are the non motor symptoms people with Parkinson’s present with
Dementia, depression, sleep disturbance, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss
What’s the first line drug treatment of motor symptoms in Parkinson’s disease where QOL is affected
Co-careldopa or benserazide
What’s the first line drug treatment of motor symptoms in Parkinson’s disease where QOL is not affected
Levodopa (non ergot derived dopamine receptor agonist)
or
monoamine oxidase B inhibitor (eg: rasagiline and selegiline)
What are nonmotor symptoms in Parkinson’s disease
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
What is the aim of treatment for Parkinson disease
As the disease is not curable the aim is to improve the quality of life of patients with Parkinson’s
When is Parkinson’s drug treatment started
When symptoms reach a level where they are causing a significant impact on daily life
Why should Anti-Parkinson drugs be initiated gradually in the elderly
Can cause confusion
Give examples of dopamine receptor agonist
Pramipexole
Ropinirole
Rotigotine
Apomorphine
What do you levodopa containing drugs interact with
MAOIs
How is using MAOBIs with levodopa useful
Reduces the ‘end-of-dose’ deterioration experience
How does Entacapone, Opicapone and Tolcapone (COMT inhibitor) work
Prevents the peripheral breakdown of levodopa giving it greater opportunity to reach the brain
Common side effect of Entacapone (COMT inhibitors)
Can colour the urine a reddish brown colour
What is prolonged levodopa use associated with
Weight loss
What can be given to treat nausea and vomiting associated with dopaminergic drugs
Domperidone
Why can dopamine agonists be preferred in the long term for younger patients
Associated with fewer dyskinesia and motor fluctuations
What negative behavioural symptom are levodopa AND dopamine receptor agonists associated with
Compulsive or disinhibited behaviour
Eg: Gambling, hypersexuality, binge eating
How are Antimuscarinic used to help Parkinson’s symptoms
Exerts it’s antiparkinsonism action by Reducing the effects of the relative Central Cholinergic excess that occurs as a result of dopamine deficiency
Drug classes involved in Parkinson’s drug treatment
- Antimuscarinic (rarely used)
- Catechol-o-methyltranferase inhibitors
- Dopamine precursors
- Dopamine receptor agonist
- Monoamine Oxidase B inhibitor
How do you phenothiazines work (eg: prochlorperazine)
They are dopamine antagonist and acts centrally by blocking the chemoreceptor trigger zone
Relieves nausea and vomiting caused by migraines
What advantage does domperidone have over metoclopramide and other phenothiazine
Less likely to cause central effects such as sedation and dystonic reactions as it doesn’t cross the BBB
What is prescribed for meniere disease (ear disease causing a spinning sensation)
Betahistine dihydrochloride
What can you buy OTC for occasional insomnia
Promethazine
What antiemetic is mostly used in post operative N&V and chemo
Serotonin antagonist (eg: ondansetron)
What antiemetic is used for delayed N&V in cisplatin chemo
Aprepitant (neurokinin 1 receptor antagonist)
What can you give to treat N&V in Parkinson’s caused by dopaminergic drugs
Domperidone
What’s the advantage of metoclopramide over other phenothiazine
It also acts directly on the gastro-intestinal tract so preferred for dmed is associated with gastroduodenal, hepatic and biliary disease
Most effective drug for the prevention of motion sickness
Hyoscine hydrobromide (Antimuscarinic)
Examples of antihistamines used for nausea and vomiting
Cyclizine
Promethazine (sedating)
When are non-opioid drugs (paracetamol and aspirin) and other NSAIDs particularly suitable
Pain in Muscoskeletal conditions
When are opioid analgesics suitable
Moderate to severe pain particularly with a visceral origin
What effect does paracetamol have
Analgesic
Antipyretic
What’s the best analgesia to use in tooth ache
NSAID (ibuprofen, aspirin, diclofenac)
Paracetamol
Common side effects of opioid use
Constipation Respiratory depression Nausea and vomiting Drowsiness Skin rash Dry mouth
Dependence
What is the most valuable opioid and the standard to which all opioids are compared
Morphine
What drug reverses opioids action
Naloxone
How is buprenorphine different to other opioids when it comes to naloxone
Naloxone only reverses it’s effects partially
Give an example of an opioid with a longer duration of action than morphine
Buprenorphine
Which opioid has less of the common opioid adverse effects
Tramadol
What’s the most widely used post operative analgesia
Combination of opioid and non-opioid
Morphine
Paracetamol
Possible adverse effects of giving opioids epidurally (unlicensed)
Pruritis
Urinary retention
Nausea and vomiting
Respiratory depression
What strengths do co-codamol come in
8/500
15/500
30/500
When is codeine contraindicated
Children younger than 12
Fast CYP2D6 ultra-rapid metabolisers
Breastfeeding mothers
Acute respiratory depression
Head injury
Signs and symptoms of morphine toxicity
Reduced conscienceness Lack of appetite Somnolence -drowsy Constipation Respiratory depression Pin point pupils Nausea and vomiting
What effect can the variation in codeine metabolism cause
Codeine is metabolised into morphine
Ultra rapid codeine metabolisers have a marked increase morphine toxicity
Poor codeine metabolisers have a reduced therapeutic effect
What do you give in neuropathic pain
Amitriptyline Gabapentin Pregabalin Tramadol Corticosteroids
What do you give for breakthrough pain
Fentanyl or morphine
Why should opioids not be used following a head injury
They interfere with neurological assessment
Why is dipapanone opioid not suitable for palliative care
It contains cyclizine
Name opioid receptor antagonist and how they work
Naloxone and naltrexone
Reverse opioid overdose and precipitate withdrawal symptoms
What medication can be used for the treatment of acute migraines
Analgesics (paracetamol aspirin)
Serotonin receptors agonist (triptans)
Ergot alkaloids
(Antiemetic if required or a combined analgesic and antiemetic)
Why are a ergot alkaloids avoided for migraine
Difficulty in absorption and by its side effects
particularly nausea vomiting abdominal pain and muscular cramps
When should preventive treatment for migraine be considered
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
What medication can you use for prophylaxis of migraine
Beta-blocker (propranolol being the most common) TCA antidepressant Gabapentin Sodium valproate/ valporic acid Pizotifen
What’s the Drug treatment of choice for cluster headache
Sumatriptan given intravenously
Oxygen for 10-20 minutes can help with an attack
When is the prophylaxis of a cluster headache indicated and what is used
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
How is Neuropathic pain managed
Tricyclics antidepressants (amitriptyline) or with certain antiepileptic drugs (gabapentin)
What can you give a patient with neuropathic pain awaiting review and unable to take oral medication
Typical local anaesthetic preparation such as
lidocaine
Or
Capsaicin
Why should you avoid the excessive use of acute treatment for migraine
It’s associated with medication overuse headache
Which non-steroidal anti-inflammatory drug is licensed specifically for acute migraine
Tolfenamic acid
How long do you have to wait before the dose of a triptan can be repeated
Atleast Two hours
Why might it be difficult to withdraw hypnotics and anxiolytics
Dependence and tolerance occur
What’s the most commonly used anxiolytic and hypnotic
Benzodiazepines
Why are older generation benzodiazepines no used as much as the newer ones
They have more adverse effects and interactions
And are more dangerous in overdose
When is benzodiazepine indicated in anxiety or insomnia
When it’s short term and severe
What is transient insomnia
Inability to sleep due to other factors like noise shiftwork jetlag etc
What is short-term insomnia
Inability to sleep due to emotional problems or illness
Which benzodiazepine are used as hypnotics normally
Nitrazepam
Temazepam
If insomnia is linked with anxiety then diazepam can be used as the hypnotic
What are the Z drugs and how do they work
Zaleon, zolpidem and Zopiclone
Not benzos but they act on the benzodiazepine receptor
What antihistamine can be used for insomnia
Promethazine (not recommended)
What age group can melatonin be used in to treat insomnia
Over 55
Why are benzodiazepine preferred over barbiturates in insomnia
Less dependence and easier to withdraw
What are paracetamol children’s dosing ages 2months - 16 years
(NEED TO ADD- Ronans notes)
What’s used as substitution in opioid dependence
Methadone or buprenorphine
What happens if a patient misses atleast 3 days of their opioid maintenance therapy
They lose tolerance and are at risk of an overdose
Why is methadone the preferred method for opioid dependence over buprenorphine
Although buprenorphine is less sedating (as its only a partial agonist) methadone is preferred as it has milder withdrawal symptoms
What do severe cases of alcohol withdrawal include
Seizures
Delirium
Death
What medications are commonly used to control alcohol withdrawal
Chlordiazepoxide (a long acting benzo)
Carbamazepine (if benzo not appropriate)
Antipsychotic may be added to control delirium
What are recovering alcoholics given to prevent relapse
Acamprosate or naltrexone
What are alcoholics given to reduce their risks of developing encephalopathy
Parental thiamine (pabrinex) Followed by oral thiamine
What can hepatitis associated with alcohol intake be treated with
Corticosteroids
What should be offered to patients trying to quit smoking
Nicotine replacement therapy in many forms
Varenicline- selective nicotine receptor partial agonist
What should be monitored with varenicline and when should it be stopped
Psychiatric performance
Stop if suicide ideation or depressed moods occur
What are common examples of drugs that when a patient stops smoking the dose need to be reduced (as smoking increases the metabolism)
Theophylline
Ropinirole
Some antipsychotics
How long would it take for untreated heroin dependence symptoms to show
8 hours
Can subside after 5 days
What is methadone lintus licensed for
As an analgesia in severe pain-and cough in terminal disease
Why should Bupropion for smoking cessation not be used in epilepsy
Lowers seizure threshold
Why should donepezil be taken in the morning
Vivid dreams have been reported
Why do people on clozapine need to take regular blood tests
It causes a severe deficiency in neutrophils (agranulocytosis)
When are benzodiazepam commonly indicated
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
What are common cholinergic (para sympathomimetics) side effects
Clue: D U M B B E L S
Diahhroa Urination Muscle weakness, cramps Bronchospasm Bradycardia Emesis (vomiting) Lactimation (teary eyes) Salivation/ sweating
What is the MHRA alert regarding antiepileptic drug switching
List the 3 catergories and the drugs in them
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
What’s the caution of taking carbamazepine with contraception?
It reduces the efficacy of hormonal contraception
Which anti epileptic drugs are present in high amounts in milk (clue: Z E L P)
Zosinanide
Ethosuximide
Lamotrigine
Primidone
What’s the MHRA alert regarding Gabapentin
Risk of severe respiratory depression
How does phenytoin work
It binds to neuronal sodium channels in their inactive state to prolong activity
Signs and symptoms of phenytoin drug toxicity (clue: S N A C H D)
Slurred speech Nystagmus (uncalled eye movement) Ataxia (uncontrolled muscle movement) Confusion Hyperglycaemia Diplopia (double vision, blurred vision)
How does carbamazepine work
It inhibits neuronal sodium channels, stabilises membrane potential and reduced neuronal exciteability
Signs and symptoms of carbamazepine toxicity (clue: I handbag)
Inco-ordination Hyponatraemia Ataxia (involuntarily muscle movement) Nystamus (involuntary eye movement) Drowsiness Blurred vision Arrhythmia GI disturbances
What’s status epilepticus and what’s the treatment
Epileptic fits follow one after the other without regaining consciousness (>5 minutes)
IV lorazepam (not diazepam as can cause thrombophlebitis)
How does methylphenidate and Dexamfetamine work, it’s drug schedule and what’s it used for
It’s a potent CNS stimulant it increases dopamine and noradrenaline levels in the brain
Schedule 2 CD
Used as first like in ADHD
What’s used in acute episodes of mania and hypo mania
Benzodiazepines
Antipsychotics (QOR)- quetiapine, olanzapine, risperidone
(Lithium or valporic acid added if antipsychotic alone is not adequate)
What’s used in the prophylaxis of bipolar disorder
Lithium salts
Valproate
Olanzapine
What’s the therapeutic range for lithium
0.4mmol- 1mmol/L
Signs and symptoms or lithium toxicity (clue: R E V N G)
Renal disturbances (excessive urination) Extrapyrimidal symptoms Visual disturbances Nervous system disturbances Gastro intestinal disturbances (vomiting and diarrhoea)
Side effects of lithium
Thyroid disorders Renal impairment Hypertension QT prolongation Lowers seizure threshold
What’s the only antidepressant safe to use on children
Fluoxetine
What antidepressant prolong QT INTERVAL
Citalopram and Escitalopram
What’s less sedating, less Antimuscarinic and less cardio toxic, TCA or SSRI
SSRI
Why does metoclopramide have a maximum 5 day use?
MHRA ALERT
It has a risk of neurological adverse effects
(EPSE due to crossing the BBB)
Why does domperidone have a maximum use of 1 week?
MHRA ALERT
Risk of cardiac side effects
Opioid side effects (clue morphine)
Miosis (pin point pupils) Out of it (sedation) Respiratory depression Postural hypotension Hallucinations Infrequency (urinary, constipation) Nausea and vomiting Euphoria
Why should codeine and dihydrocodeine never be given via the IV route?
Severe reaction similar to anaphylaxis
CD2 when given the IM route
Why’s codeine not given to children under 12
Can cause breathing problems
The metabolism into morphine is unknown
What drugs lower seizure threshold
Tramadol
TCA
SSRI
What’s used for anxiety
Benzodiazepines
Barbiturates
Buspirone
Of the meds used for anxiety, which ones not a sedative
Buspirone
What do you monitor with phenobarbital
CLUE: LOW AND SLOW
Low respiratory
Low blood pressure
Sedation
In terms of the patients bloods, when is giving lithium contraindicated
Hyponatraemia
Dehydration
What needs to be counselled for a patient starting carbemazipine and on oral contraception?
Oral contraceptives not effective will need alternative birth control method
What’s an important possible adverse effect of donepezil
Neuroleptic malignant syndrome
Which side effect should galantamine be stopped immediately
First appearance of a skin rash
Risk of SJS
What is important to note with contraception and antiepileptic
Enzyme inducing antiepileptics (eg: carbamazepine) reduce the efficiency of hormonal contraception
Which antiepileptic are present in high amounts in breast feeding milk (clue ZELP)
Zosinamide
Ethosuximide
Lamotrigine
Primidone
What would you give for a convulsive status epilepticus?
IV lorazepam
Avoid IV diazepam as it causes thrombophlebitis
What’s the MHRA alert for the nsaid piroxicam
Should not exceed 20mg OD
Which NSAID is best to give to a patient with high CV risk
Ibuprofen <1.2g daily
Naproxen <1g
Which drugs can cause Parkinsonism symptoms
Cinnarizine Flunarozine Pet hiding Sodium valproate Amiodarone Metoclopramide
Why should Z drugs and benzodiazepines be avoided in elderly
Ataxia and confusion = falls/ injury
What vitamin deficiency can excess alcohol cause
Vitamin B1 (thiamine)
What needs to be monitored with methylphenidate for ADHD and why
Weight and height
As it can affect the growth of some children
Which antidepressant drug can increase the risk of bleeding
Sertraline
How many weeks can it take for buspirone to work
Up to 2 weeks
What’s the wash out period for the different anti depressants
MOAI wait 2 weeks
SSRI wait 1 week
TCA wait 1-2 weeks (3 weeks if imipramine or clomipramine)
How long does it take for buspirone to work
2 weeks
Common adverse effect of pizotifen (used for headaches)
Weight gain
Which antiepileptic carried an increased risk of cleft palates if taken in the first trimester or pregnant
Topiramate
Lithium and ACEi interaction
ACEi increased the concentration of lithium
What needs to be monitored and how often with lithium
BMI
Serum electrolytes
Renal function
Thyroid function
Every 6 months
What do you give for Alzheimer’s disease for a patient with Parkinson’s disease
Rivastagmine
What’s given for non cognitive symptoms of dementia including extreme violence, aggression and extreme behaviour
Oral benzodiazepines
Or
Antipsychotics
(If IM needed lorazepam, halopiredol, olanzapine)
Most antiepileptics are BD dosing, name the OD ones
Lamotrigine
Perampanel
Phenytoin
Which antiepileptic require you to monitor foetal growth
Topiramate
Levetiracetam
What’s advices for women to take when they become pregnant and on anti epileptics
5mg folic acid until 12 weeks
Which antiepileptic can inhibit sucking reflex in babies
Phenobarbitals and primidone
What’s febrile convulsions and what’s used for it
Seizures that occur when a child has a high fever
Paracetamol (antipyretic)
If >5 minutes treat as a status epilepticus (IV lorazepam)
Psychological symptoms of anxiety
Restlessness Worry Fear Difficulty swallowing Irritability
Physical symptoms of anxiety
Palpitations Muscle aches and tension Trembling and shaking Excessive sweating SOB Insomnia
Whens lithium blood samples taken
12 hours after dose
Counselling for diet on lithium
Don’t have significant changes to your diet especially sodium
Which antidepressants have a higher risk of withdrawal reactions
Paroxetine
Venlafaxine
MHRA alert for clozapine
GI obstruction
What’s used in advanced Parkinson disease
Apomorphine
What strength of morphine oral solution counts as a CD5
13mg/5ml or less
The first line parenteral route for opioids
Diamorphine (heroin)
What’s the equivalent diamorphine dose to morphine
1/3 of the morphine dose
What should you counsel with patch medications
Avoid exposure to external heat (eg: sauna) as it results in increased absorption
And rotate patch site
What’s the MHRA advice for codeine use in 12-18 year olds
Max 240mg a day for 3 days
Which opioid also affect the noradrenaline and serotonin uptake
Tramadol
What interactions does tramadol have
It lowers seizure threshold
Bleeding risk (warfarin)
Serotonin syndrome
What can you use for conscious sedation of dental procedures
Temazepam
Which SSRI has a long half life
Fluoxetine
Epilepsy treatment options in kids
Sodium valproate
Leveretacium
Topiramate
Is routine plasma concentration required for lithium and sodium valproate
No
Interactions with lithium
ACEi - lithium toxicity
NSAIDs- lithium toxicity
Diuretics- hyponatraemia
Amiodarone- risk of arrhythmia
What should be counselled when giving disulfiram (treatment of alcohol dependence)
Alcohol should be avoided atleast 1 week after therapy has stopped
Patients should not ingest alcohol at all as there a serious interaction
Can you breast feed while on anti epileptics drugs
Yes safe with nearly all of them
Is opioid analgesic safe to use in pregnancy
Contraindicated in the 3rd trimester as it can depress neonatal respiration
How can you treat neuroleptic malignant syndrome
Dopamine receptor agonist
Bromocriptine or Dantrolene
Why would you caution metoclopramide in female adolescents
Extrapyramidal side effect
What’s preferred for motion sickness when the journeys long
Old generation antihistamines as they have a long mode of action
Why should patients be adviced to take migraine meds straight away on an onset of an attack
When migraine occurs gastric emptying slows down so absorption is reduced
When do you refer for a migraine?
Symptoms occurring for the first time
Migraine in a child
Medication not relieving symptoms
First migraine occurred after the age of 40
What medications are sold otc for insomnia
Diphenhydramine (treatment of choice) and promethazine
What is epilepsy
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
Which dementia is drug treatment not recommended for
Vascular dementia
And with the others should only be continued if there’s behavioural or cognitive benefit
What can be given to minimise neonatal haemorrhage in newborns where the mother was taking anti epileptic medication
Vitamin K injection
Which medication can cause the most withdrawal effects from the mother taking them in newborns
Benzodiazepine
Phenobarbital
What should all breastfed infants where the mothers taking antiepileptic medications be monitored for
Drowsiness Weight gain Feeding difficulty Adverse effects Developmental milestones
What has MHRA reported with all antiepileptic drugs
Increased with of suicidal behaviour and thoughts and
Which antiepileptic medication cause blood dyscrasias and should report signs of infections
‘C vet pls’
Carbamazepine Valproate Ethosuximide Topiramate Phenytoin Lamotrigine Zonisamide
What antiepileptic medication can cause eye problems
Vigabatrin (visual symptoms)
Topiramate (raised intra ocular pressure)
Name a few CNS depressants
Benzodiazepines Opioids Hypnotics Barbiturates Antipsychotics Lithium Antidepressants Alcohol Antiepileptic
Side effects of phenytoin
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
Side effects of carbamazepine
Blood dyscrasias Hepatotoxicity Hypersensitivity reaction Rashes (chinese and Thai patients with HLAV*1502 allele are at risk of Sjs) Hyponatraemia
What’s the conditions of PPP for valproate supply
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
What do the nations of the pharmacist include everytime they dispense valproate
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
Side effects of valproate
Hepatotoxicity (fatal)
Blood dysrasias
Pancreatitis
Monitor: liver function test and full blood count
How would you withdraw diazepam
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
What should the withdrawal period be for antipsychotics
4 weeks of still being treated with other anti manic meds
3 months of completely stopping
How long should prophylactic treatment of bipolar disorder be continued
2 years from last manic episode
5 years if experienced a relapse
What concentration are you likely to experience toxic effects with lithium
2mmol/ L
Which antidepressant doesn’t require a washout period
Moclobemide
Due to the short acting/ reversible action
What’s the washout period for fluoxetine
5 weeks
What determines the choice of antipsychotic
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
How long should you give to assess clozapine response
8-10 weeks
How many missed doses of clozapine till it needs to be referred to specialist
2 or more missed doses
Side effect of the antipsychotic pimozide
Qt prolongation, cases of sudden death
What does selegiline metabolise to
Amphetamine
What should be added to parkinsons id dyskinesia is not adequately managed by modifying therapy
Amantadine
What’s reserved advanced Parkinson’s disease and what’s the use
Apormorphine
Used in motor fluctuations in the off period
What’s the use of carbidopa and beserazide
To get more levodopa into the brain with a smaller dose
Transporter
Whys it important to take levodopa at a specific time each day
To avoid off periods
Why are Ergot derived medication not used in Parkinson disease
Side effect of fibrotic reactions
Why’s entacapone preferred over tolcapone
Tolcapone can cause loose threatening hepatotoxicity
What’s break through pain?
Sudden flare of Pain that breaks through regular medication
What’s the doses of rescue dose
Min 1/10th
Max 1/6th
Of the total dose of strong opioid every 2-4 hours PRN
Cautionary and advisory labels on opioids
Warning. This medication may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol
What increments can morphine be increased
1/3 or 1/2 total daily dose per 24hours
What parental dose is equivalent to an oral dose
Parental dose is equivalent to half the oral dose
What’s the equivalent dose of diamorphine to oral morphine
Diamoprhine is equivalent to 1/3 of oral morphine
How long can buprenorphine patches last
Fentanyl?
3, 4 or 7 days
Fentanyl- 3 days
What can be used to treat daytime symptoms in Parkinson’s patients
Modafinil
Why does carbamazepine have a higher maintenance dose than losing dose
It is an enzyme auto inducer
So it induces its own metabolism so maintenance dose is higher than the initial dose
What’s the interaction between sumatriptan and tramadol
Both increase the risk of serotonin syndrome
Which antiemetics are less teratogenic
Lamotrigine and levetiracetam