CNS Flashcards
epilepsy withdrawing drugs?
one at at time!
LITHIUM MONITORING?
65+?
LITHIUM MONITORING? weekly till stable, every 3 months first year, every 6 months thereafter
65+? every 3 months (poor control, poor renal, etc)
EPILEPSY ATTACK, alcohol ting
Immediate measures to manage status epilepticus include positioning the patient to avoid injury, supporting respiration including the provision of oxygen, maintaining blood pressure, and the correction of any hypoglycaemia. Parenteral thiamine should be considered if alcohol abuse is suspected; pyridoxine hydrochloride should be given if the status epilepticus is caused by pyridoxine hydrochloride deficiency.
EPILEPSY INFANTS SECTION?
NEUROPATHIC PAIN
TOPICAL LOCALISED?
LIDOCAINE/
CAPSAICIN (intense burning sensation may limit use)
NEUROPATHIC PAIN
OPIATES?
MORPHINE/OXYCODONE/TRAMADOL
that order
tramadol not rated
NEUROPATHIC PAIN
ANTIEPILEPTICS?
GABAPENTIN/PREGABALIN (1 week withdrawal regimen)
NEUROPATHIC PAIN
TCAs?
AMITRIPTYLINE/NORTRIPTYLINE
FENTANYL PATCHES?
REMOVE PATCH IMMEDIATELY IF THERE ARE SIGNS OF TOXICITY
PATCHES ADVICE?
AVOID EXPOSURE TO HEAT
APPLY TO DRY HAIRLESS AREA
ROTATE SITE
OXYCODONE MORE POTENT THAN MORPHINE?
More appropriate, less nausea
SWTICHING BETWEEN OPIATES TO PREVENT OD?
REDUCE DOSE BY 1/2 TO 1/3
Patient on 120mg morphine, dose increase?
Max. increase by 1/3 to 1/2 each day, i.e.
40-60mg increase
???
STRONG OPIATES
BREAKTHROUGH PAIN?
1/6th- 1/10th of total daily dose, /2-4hours
STRONG OPIATES
AVOID IN…?
PARALYTIC ILEUS
RESPIRATORY DISEASE HEAD INJURY
?????
STRONG OPIATES
OVERDOSE?
GIVE NALOXONE
STRONG OPIATES
PROLONGED USE SIDE-EFFECTS?
HYPOGANADISM- less hormone secretion
ADRENAL INSUFFICIENCY- heightened sensitivity to pain
HYPERALGESIA
OPIATES SIDE-EFFECTS?
Act on mu-pathway causing: DRY MOUTH CONSTIPATION CNS DEPRESSION N&V HYPOTENSION MIOSIS (pupil constriction)
CODEINE
AGE?
AVOID IN x3?
AGE? 12+ (Linctus- 18+?)
AVOID IN x3?
U18 children who had tonsils remove due to sleep apnoea
(Afro-Caribbean) patients who are ultra-rapid metaboliser due to toxicity?
Breastfeeding
Children under 12, respiratory side-effects!
PAIN MANAGEMENT
MODERATE-SEVERE?
ALL THE CDs!
STRONG OPIATES: MORPHINE/OXYCODONE/METHADONE/BUPRENORPHINE/FENTANYL
PAIN MANAGEMENT
MILD-MODERATE?
WEAK OPIATES: CODEINE/DIHYDROCODEINE
MODERATE: TRAMDOL (but lowers seizure threshold, serotonin syndrome, risk of bleed, psychiatric disorder
PAIN MANAGEMENT
MILD?
NON-OPIATES: PARACETAMOL/NSAIDs/ASPIRIN
METOCLOPRAMIDE
SIDE-EFFECTS?
DOSE?
MINIMUM AGE?
MAX. DAYS?
SIDE-EFFECTS? EPse, crosses BBB
DOSE? 10mg TDS (samesame)
MINIMUM AGE? 18 years old
MAX. DAYS? 5
DOMPERIDONE
DOES NOT CROSS?
DOSE?
MINIMUM AGE?
MAX. DAYS?
MINIMUM WEIGHT?
SIDE-EFFECT?
DOES NOT CROSS? The BBB, so used in PD, SO WHAT
DOSE? 10mg TDS
MINIMUM AGE? 12 years old
MAX. DAYS? 7
MINIMUM WEIGHT? 35kg+
SIDE-EFFECT? QT prolongation
PARKINSON’S N&V?
DOMPERIDONE
Haloperidol/Levmepromazine-> antipsychotics, reduce dopamine levels, L
HYPOTENSION RISK!
PREVENTION & TREATMENT OF POSTOPERATIVE N&V CAUSED BY OPIOIDS/GENERAL ANAESTHETICS?
CYCLIZINE
PALLIATIVE CARE N&V?
HALOPERIDOL/LEVOMEPROMAZINE
MOTION SICKNESS?
hysocine HYDRObromide
hyoscine BUTYLbromide (GI system)
PREOPERATIVE ANTICIPATORY?
LORAZEPAM (short-acting)
POSTOPERATIVE N&V?
POSTOPERATIVE N&V?
5HT-3 receptor antaognist (Ondansetron)/Dexamethasone
PROPHYLAXIS/TREATMENT OF N&V
PREGNANCY?
SEVERE VOMITING?
PREGNANCY?
Nausea in first trimester- generally mild/does not require drug therapy
SEVERE VOMITING?
Short-term treatment-> anithistamine, e.g. promethazine/prochlorperazine/metoclopramide
PROPHYLAXIS/TREATMENT OF N&V?
PROPHYLAXIS/TREATMENT OF N&V?
Antihistamines- Cyclizine/Promethazine
Phenothiazines- Prochlorperazine
TENSION HEADACHE
SYMPTOM?
TREATMENT?
SYMPTOM?
Bilateral throbbing pain-> tight band around your head
TREATMENT?
Paracetamol/Ibuprofen
TRIGEMINAL NEURALGIA
SYMPTOM?
TREATMENT?
SYMPTOM?
Severe facial pain, electric shock-like in jaw/teeth/gums
TREATMENT?
Carbamazepine
CLUSTER HEADACHES TREATMENT
ACUTE?
PROPHYLAXIS? VLP-E
ACUTE? SC sumatriptan (give nasal sumatriptan/zolmitriptan if unavailable)
PROPHYLAXIS?
Verapamil/Lithium/Prednisolone/Ergotamine tartate (rare)
HEADACHES
CLUSTER SYMPTOM?
INTENSE UNILATERAL PAIN IN/AROUND ONE EYE
TRIPTANS CONTRAINDICATED IN..?
IHD HYPERTENSIONS PVD MI TIA ANYTHING HEART! (as it narrows blood vessels)
MIGRAINE PROPHYLAXIS
TOPIRAMATE?
Caution in women of child-bearing potential
Advice on risks during pregnancy
Teratogenic- cleft palate in first trimester
MIGRAINE PROPHYLAXIS
EPISODIC/CHRONIC
Unlicensed Treatment?
Limited Evidence?
EPISODIC/CHRONIC?
UNLICENSED- SODIUM VALPROATE/FLUNARIZINE
Limited evidence- PIZOTIFEN
MIGRAINE PROPHYLAXIS
AMITRIPTYLINE is effective BUT if not tolerated..?
AMITRIPTYLINE is effective BUT if not tolerated..?
Use less sedating TCA
MIGRAINE PROPHYLAXIS
1st LINE?
2nd LINE?
1st LINE? PROPRANOLOL
2nd LINE? METOPROLOL/NADOLOL
VALPROATE/PIZOTIFEN/BOTOX ALSO USED…
ACUTE MIGRAINE
ANTIEMETICS?
Metoclopramide/Prochlorperazine (unlicensed) can be given as single dose at onset of migraine symptoms
Don’t use Metocopramide regularly- EPse (5 days)
Domperidone- unlicensed in <35kg (7 days)
ACUTE MIGRAINE
Unable to take first-line options?
Give souble paracetamol
ACUTE MIGRAINE
W/ AURA?
REPEAT?
W/ AURA?
Take triptan at the START of headache and NOT at the start of aura
REPEAT?
Repeat Triptans after 2 hours (Naratriptan 4 hours) ONLY if there has been a response to 1st dose (but inadequate)
MIGRAINE
ACUTE TREATMENT 1ST LINE?
ACUTE TREATMENT?
Aspirin/Ibuprofen/5HT-1 receptor agonist (Sumatriptan favoured)
take as soon as patient knows they’ve got a migraine
MIGRAINE
LIFESTYLE ADVICE?
LIFESTYLE ADVICE? Maintain hydration/sleep/exercise Avoid chocolate+wine Relax after stress Headache diary- identify triggers
MIGRAINE
W/ AURA SYMPTOMS?
W/ AURA SYMPTOMS?
Visual (zigzag/flickering lights, spots, lines)
Sensory (pins & needles, numbness)
Dysphasia
MIGRRAINES
SYMPTOMS?
Unilateral/pulsating
N&V, photophobia & phonophobia
OPIOID DEPENDENCE
METHADONE?
METHADONE?
Causes QT prolongation
Carefully titrate according to patient’s needs
OPIOID DEPENDENCE
x4 BUPRENORPHINE KEY POINTS?
x4 BUPRENORPHINE KEY POINTS? Less sedating than methadone Milder withdrawal symptoms Lower risk of OD Suboxone (buprenorphine w/ naloxone) given when there is risk of injecting
OPIOID DEPENDENCE?
High risk of overdose?
High risk of overdose? Naloxone
OPIOID DEPENDENCE
PREGNANCY?
PREGNANCY? Continue treatment
OPIOID DEPENDENCE
MISSED 3 DAYS OR MORE?
MISSED 3 DAYS OR MORE? Risk of OD, loss of tolernace, consider reducing dose, refer to specialist
OPIOID DEPENDENCE
Prescribed on form?
Prescribed on form? FP10MDA-> max. supply of 14 days
NICOTINE DEPENDENCE
NICOTINE-REPLACEMENT THERAPY (NRT)?
NICOTINE-REPLACEMENT THERAPY (NRT)?
Use a patch (16-hr if pregnant/nightmares) AND
Use a short-term reliever: lozenges/gum/sublingual tablets/inhalator/nasal/oral spray
NICOTINE DEPENDENCE
BUPROPION?
BUPROPION?
Avoid in psychiatric illness/seizures/eating disorders
NICOTINE DEPENDENCE
VARENICLINE?
VARENICLINE?
Avoid in epilepsy/cardiovascular disease/psychiatric illness
ALCOHOL DEPENDENCE
WERNICKE’S ENCEPHALOPATHY TREATMENT?
WERNICKE’S ENCEPHALOPATHY TREATMENT? Thiamine (Vitamin B1)
ALCOHOL DEPENDENCE
DELIRIUM TREATMENT?
DELIRIUM TREATMENT? Lorazepam
ALCOHOL DEPENDENCE
WITHDRAWAL SYMPTOMS TREATMENT?
WITHDRAWAL SYMPTOMS TREATMENT?
L-A benzodiazepine, e.g. Chlordiazepoxide/Diazepam (alternative: carbamazepine/clomethiazole)
ALCOHOL DEPENDENCE
TREAT WITH?
TREAT WITH? CBT->Acamprosate/Naltrexone (alternative: disulfram)
SUBSTANCE DEPENDENCE
ALCOHOL DEPENDENCE
MILD?
MODERATE?
SEVERE?
MILD? Do not need assisted alcohol withdrawal
MODERATE? Treated in a community setting, unless high risk of developing alcohol withdrawal seizures/delirium
SEVERE? Undergo withdrawal in an inpatient setting
LISDEXAMFETAMINE & DEXAMFETAMINE
OVERDOSE signs?
TREATMENT?
OVERDOSE?
Amfetamines cause: wakefulnness/excessive activity/paranoia/hallucinations/hypertension
Followed by: exhaustion/convulsions/hyperthermia/coma
TREATMENT? diazepam/lorazepam
LISDEXAMFETAMINE & DEXAMFETAMINE
SIDE-EFFECTS & MONITORING?
Similar to METHYLPHENIDATE
METHYLPHENIDATE
SIDE-EFFECTS?
MONITOR? BPPAWH
SIDE-EFFECTS? CNS stimulant Hypertension/Tachycardia/Arrythmias Mood change/Drowsiness/Sleep disorders Decreased appetite/Weight loss Growth retardation (children)
MONITOR? At initiation/after dose adjustments/6 monthly Pulse BP Psychiatric symptoms Appetite Weight Height
ADHD
MR-prep preferred?
MR-prep preferred? Because of their.. pharmacokinetic profile convenience improved adherence
PRESCRIBE AS BRAND ONLY
ADHD- ADULT TREATMENT
1st LINE?
2nd LINE?
1st LINE?
Use methylphenidate/lisdexamfetamine (dexamfetamine if patient can’t tolerate long duration of action)
2nd LINE?
Atomoxetine (causes QT prolongation, hepatotoxicity & suicidal ideation
ADHD
Children intolerant of both methylphenidate & lisdexamfetamine?
Children intolerant of both methylphenidate & lisdexamfetamine?
Atomoxetine
Guanfacine (unlicensed)
ADHD
> /= 5years?
> /= 5years?
1) Methylphenidate, first-line
2) If 6 week trial of methylphenidate at max. tolerated dose NOT reduce symptoms? switch to Lisdexamfetamine (Dexamfetamine, unlicensed, used if patients cannot tolerate longer duration of action of Lisdexamfetamine)
Z-HYPNOTICS
Benzodiazepines+Z-drugs?
SIDE-EFFECTS? PD^2
Benzodiazepines (clonazepam/lorazepam)+Z-drugs? Avoid in elderly due to risks of fall and injury
SIDE-EFFECTS? PD^2
Paradoxical side-effects
Drowsiness
Dependance
Z-HYPNOTICS
Examples? Increases GABA? Dependency? When to take it? Max. duration?
Examples? Zolpidem/Zopiclone
Increases GABA? ->CNS depression
Dependency? Occurs within 3-14 days of use
When to take it? Taken intermittently
Max. duration? Use for 4 weeks max.
BENZODIAZEPINES
SHORT-ACTING BENZODIAZEPINES? LLT
SHORT-ACTING BENZODIAZEPINES? Loporazolam/Lormetazepam/Temazepam
Little/no hangover effects
Used for sleep onset
Higher chance of withdrawal symptoms
BENZODIAZEPINES
LONG-ACTING BENZODIAZEPINE? NDF sleep
LONG-ACTING BENZODIAZEPINE? Nitrazepam/Diazepam/Fluarazepam
Higher hangover effect following day
Used for sleep maintenance
BENZODIAZEPINES
LONG-ACTING BENZODIAZEPINE? ADC^2
ALPRAZOLAM
DIAZEPAM
CHLORDIAZEPOXIDE HYDROCHLORIDE
CLOBAZAM
Can induce hepatic coma, especially long-acting benzodiazepines
SLEEP DISORDERS
CHRONIC INSOMINA?
CHRONIC INSOMNIA? cause: anxiety/depression/alcohol/drug abuse
Treat underlying psychiatric complaint
SLEEP DISORDERS
SHORT-TERM INSOMNIA?
SHORT-TERM INSOMNIA? emotional problem/serious medical illness
Hypnotic is useful, don’t give more than 3 weeks (1 week ideal)
SLEEP DISORDERS
TRANSIENT INSOMNIA?
TRANSIENT INSOMNIA? external factors- noise, shift work & jet lag
Give rapidly eliminated hypnotic- only 1/2 doses
SLEEP DISORDERS
TRANSIENT INSOMNIA?
TRANSIENT INSOMNIA? external factors- noise, shift work & jet lag
Give rapidly eliminated hypnotic- only 1/2 doses
MAO-I Washout Periods
Don’t start MAOI until…
Don’t start MAOI until…
- 2 weeks after a previous MAOI has been stopped (0 weeks for moclobemide)
- 1-2 weeks after a TCA (3 weeks for clomipramien/imipramine)
- 1 week after an SSRI (5 weeks for fluoxetine)
MAO-I Washout Periods
Other antidepressants should not be started…
Other antidepressants should not be started…
For 2 weeks after treatment with MAOIs (3 weeks if clomipramine/imipramine)
x5 MAO-INHIBITORS KEY POINTS?
Specialist use
Causes hepatoxicity
(phenelzine+isocarboxazid)
Hypertensive crisis- DO NOT GIVE OTC pseudoephedrine
AVOID tyramine-rich foods
Tranylcypromine+Clomipramine= FATAL
TRICYCLIC ANTIDEPRESSANTS- INTERACTIONS?
INTERACTIONS?
CYP inhibitors (grapefruit, increases conc)
CYP inducer (reduces effectiveness)
QT prolongation (amiodarone, sotalol, quinolone)
Anti-muscarinic drugs (oxybutynin, solifenacin, tamsulosin)
Anti-hypertensive drugs
Hyponatraemia
TRICYCLIC ANTIDEPRESSANTS
SIDE-EFFECTS? CASHH
SIDE-EFFECTS? CASHH Cardiac events Anti-muscarinic Seizures Hypotension Hallucinations
DANGEROUS IN OVERDOSE
TRICYCLIC ANTIDEPRESSANTS
DANGEROUS OD?
DANGEROUS OD?
Amitriptyline/Dosulepin- dangerous in overdose, not recommended for depression, specialist-led!
TRICYCLIC ANTIDEPRESSANTS
LESS SEDATING? NIL
LESS SEDATING? better for withdrawn/apathetic patients
Nortriptyline
Imipramine
Lofepramine
TRICYCLIC ANTI-DEPRESSANTS
SEDATING? Better for who? A C D T
SEDATING? better for agitated/anxious patients Amitriptyline Clomipramine Dosulepin Trazodone
WHAT IS SEROTONIN SYNDROME? CAN
CAUSED BY?
CAN
Cognitive: headache, agitation, hypomania, confusion
Autonomic: sweating, hyperthermia, nausea, diarrhoea
Neuromuscular Excitation: myoclonus, tremor, teeth grinding
CAUSED BY? SSRIs, TCAS, MAO-Is Triptans Tramadol Lithium
SSRIs- INTERACTIONS?
C^2QBHS
CYP inhibitors (grapefruit, increases plasma conc.)
CYP inducers (St John’s wart, phenobarbital, phenytoin, less effective)
QT prolongation (amiodarone, sotalol, quinolone- cipro, levo, macrolides)
Bleed
Hyponatraemia (carbamazepine, diuretics)
Serotonin Syndrome
SSRIs- SIDE EFFECTS? GASHBIQ
GASHRIQ GI Disturbances Appetitite/Weight Gain Sexual Dysfunction Hyponatraemia Bleed (avoid NSAIDs, warfarin, PPI key) Insomnia (take OM) QT Prolongation (Escitalopram/Citalopram)
SSRIs- x3 KEY POINTS?
Better tolerated
Safer in OD
Safest in patients w/ cardiac events
SERTRALINE= SAFE, CVD
Depression 5-17 years, SSRI?
Fluoxetine
DEPRESSION- TREATMENT?
1st line?
DOES NOT WORK?
1st line? SSRI (fluoxetine, sertraline, citalopram)
DOES NOT WORK? Increase dose Change SSRI Mirtazapine MAO-I (specialist) TCA/Venlafaxine (severe)
Still doesn’t work? Add in lithium OR antipsychotics
Use electroconvulsive therapy in severe refractory depression
DEPRESSION
MILD?
MODERATE-SEVERE?
MILD? CBT
MODERATE-SEVERE? Antidein fpressants
Patient may feel worse in first 1-2 weeks
Take for 4 weeks (6 in elderly) before deemed ineffective
Take for…
6 months after remission
1 year in elderly
2 years in recurrent
DEPRESSION is?
A reduction of serotonin/dopamine/norephedrine at the synaptic cleft
BENZODIAZEPINES- WITHDRAWAL
Withdrawal symptoms?
3 STEPS?
Withdrawal symptoms? anxiety/sweating/weight loss/tremors/loss of appetite
3 STEPS?
1) Convert all meds to diazepam x1 ON
2) Reduce by 1-2mg (1/10th on larger doses) /2-4 weeks
only further withdraw if patient has overcome withdrawal symptoms
3) Reduce further (0.5mg near the end)
BENZODIAZEPINE SIDE-EFFECTS?
COLD FT LEGAL LIMIT?
OD TREATMENT?
- PARODOXICAL- aggression, hostility, talkative
- SEDATION- increased w/ alcohol use/CNS depressant/CYP inhibitors
-AVOID driving if drowsy- legal limit (COLD FT) Clonazepam Oxazepam Lorazepam Diazepam Flunitrazepam Temazepam
OD TREATMENT?
Flumazenil- can prevent need for ventilation (avoid in OD TCA mixed)
Activated charcoal can be given within 1 hour of ingesting a significant quantity of benzodiazepine- if patient awake+protected airway
BENZODIAZEPINES-
CAN INDUCE?
LONG-ACTING?
SHORT-ACTING?
CAN INDUCE?
Hepatic coma, especially long-acting
LONG-ACTING? DC^2
Diazepam
Chlordiazepoxide
Clobazam
SHORT-ACTING?
Lorazepam (epilepsy) quick to act
Oxazepam
S-A preferred in hepatic impairment/elderly BUT…
S-A greater risk of withdrawal symptoms (max. 2-4 weeks use)
ANXIETY- TREATMENT
ACUTE?
CHRONIC?
ACUTE? Lorazepam/Diazepam- short term use, lowest dose
CHRONIC?
SSRIs- sertraline, citalopram, fluoxetine
Propranolol- alleviates physical symptoms only
CLOZAPINE- SIDE-EFFECTS?
MAG
Myocarditis+Cardiomyopathy- report+stop on tachycardia
Agranulocytosis+Neutropenia- monitor leucoyes+diff. BC (report infection symptoms)
GI Disturbances: report+stop on constipation->intestinal block
CLOZAPINE- HIGH-RISK DRUG
USED IN? WHEN?
MISSED MORE THAN 2 DOSES?
MONITOR X? WHEN?
USED IN? WHEN? Resistant schizophrenia when…
2+ antipsychotics including a 2nd gen has been used for 6-8weeks each
MISSED MORE THAN 2 DOSES?
Specialist reinitiation
MONITOR X? WHEN? Leucocytes+diff. BC…
Weekly for 18 weeks
Fortnightly till 1 year
Monthly
ANTIPSYCHOTICS- MONITORING?
WEIGHT?
FBG/HBA1c/LIPIDS/BLOOD PRESSURE?
ECG?
FBC/U&Es/LFTs?
PROLACTIN?
WEIGHT?
Start, weekly 1st 6 weeks, 12 weeks, 1 year, then /year.
FBG/HBA1c/LIPIDS/BLOOD PRESSURE?
Start, 12 weeks, 1 year, then /year
ECG?
Before initiation
FBC/U&Es/LFTs?
Start, then /year
PROLACTIN?
Start, then /6months then /year
ANTIPSYCHOTIC SIDE-EFFECTS?
HYPOTENSION? CQ
HYPERGLYCAEMIA? CiROQ
WEIGHT GAIN? COw
NEUROLEPTIC MALIGNANT SYNDROME?
HYPOTENSION? Clozapine/Quetiapine
HYPERGLYCAEMIA? CiROQ Clozapine Risperidone Olanzapine Quetiapine
WEIGHT GAIN? COw
Clozapine
Olanzapine
NEUROLEPTIC MALIGNANT SYNDROME?
STOP->TREAT W/ BROMOCRIPTINE->SHOULD RESOLVE IN 5-7 DAYS
ANTIPSYCHOTIC SIDE-EFFECTS
EXTRAPYRAMIDAL S-E?
HYPERPROLACTINAEMIA?
SEXUAL DYSFUNCTION?
CARDIOVASCULAR S-E?
EXTRAPYRAMIDAL S-E? MOST in Group 3 Phenothiazine+Butyrophenones (fluphenazine/haloperidol)
HYPERPROLACTINAEMIA? LEAST in Aripiprazole
SEXUAL DYSFUNCTION? ALL antipsychotics
CARDIOVASCULAR S-E? QT prolongation, MOST common w/ pimozide+haloperidol
ATYPICAL 2ND-GEN ANTIPSYCHOTICS?
AMISULPRIDE ARIPIPRAZOLE (least side-effects) CLOZAPINE QUETIAPINE RISPERIDONE
NEVER USE HALOPERIDOL AS ANTI-EMETIC IN PARKINSON’S DISEASE PATIENTS! EPSE
SIDE-EFFECTS?
BUTYROPHENONES?
THIOXANTHENES?
DIPHENBUTYLPIPIERIDINE/SUBSTITUTED BENZAMIDE?
BUTYROPHENONES? haloperidol high EPSE (g3 similar)
THIOXANTHENES? flupentixol
Moderate sedation+antimuscarinic effects+EPSEs
DIPHENBUTYLPIPIERIDINE/SUBSTITUTED BENZAMIDE? pimozide/sulpiride
Reduced sedation+antimuscarinic effects+EPSEs
PHENOTHIAZINE 3 GROUPS?
GROUP 1?
GROUP 2?
GROUP 3?
GROUP 1? chlorpromazine, levomepromazine
Most sedation
GROUP 2? pericyazine
Least EPSEs
GROUP 3? fluphenazine, prochlorperazine
High EPSEs
TYPICAL FIRST-GEN ANTIPSYCHOTICS SIDE-EFFECTS?
Block dopamine d2-receptors in the brain
Extrapyramidal symptoms
Hyperprolactinaemia
TYPICAL FIRST GENERATION ANTIPSYCHOTICS- 5 TYPES
Phenothiazine? Butyrophenones? Thioxanthenes? Diphenbutypiperidines? Substituded benzamides?
5 TYPES? PBTDS Phenothiazine- chlorpromazine, levomepromazine Butyrophenones- haloperidol Thioxanthenes- zuclopenthixol Diphenbutypiperidines- pimozide Substituded benzamides- sulpirie
PSYCHOSIS+SCHIZOPHRENIA
POSITIVE SYMPTOMS?
NEGATIVE SYMPTOMS?
POSITIVE SYMPTOMS?
Delusions
Hallucinations
Disorganisation
NEGATIVE SYMPTOMS?
Social withdrawal
Neglect
Poor hygiene
ANTI-PARKINSONS MEDS
Withdrawal?
Off periods?
Nocturnal Akinesia-
1st line?
2nd line?
Hypotension?
Sudden onset of sleep?
KEY POINTS?
-Do not withdraw medications abruptly
-Person has ‘off periods’ (med wearing off, no longer optimal) due to end of dose deterioration | nocturnal immobility-> use MR prep
-Nocturnal akinesia- treat with
1st line: levodopa/oral dopamine receptor agonist, i.e bromocriptine, cabergoline
2nd line: rotigotine
Hypotension? Midodrine
Sudden onset of sleep? Modafinil
ERGOT-DERIVED DOPAMINE RECEPTOR AGONISTS- BC EXAMPLE?
SIDE-EFFECTS?
BROMOCRIPTINE/CABERGOLINE
SIDE-EFFECTS? FIBROTIC REACTIONS!!!
Pulmonary reactions: SOB, chest pain, cough
Pericardial reactions: Chest pain
What do you do if symptoms are not controlled with a NEDR-A as adjunct to levodopa?
Add EDR-A instead, w/ levodopa
COMT INHIBITORS, ET
SIDE-EFFECTS?
ENTACAPONE/TOLCAPONE
SIDE-EFFECTS? Entacapone- red-brown urine Tolcapone- hepatotoxic Increases sympathetic S-E- increase in CVD events (tachycardia, fast breathing..)
If patient develops dyskinesia/motor fluctuations w/ optimal levodopa, WHAT DO YOU DO?
Add an adjuvant:
- Non-ergotic dopamine receptor agonist (NEDR-A)/monoamine oxidase B inhibitor
- COMT inhibitor
MONOAMINE-OXIDASE-B INHIBITORS
SIDE-EFFECTS?
RASAGILINE/SELEGILINE
SIDE-EFFECTS?
Hypertensive crisis if given w/ phenylephrine/pseudoephedrine
Interacts w/ Tyramine-rich foods: Mature cheese Salami Marmite Yeast Tofu /Meat Yeast Extract Some beers/wines
NOR-ERGOT-DERIVED DOPAMINE RECEPTORS- PR^2
SIDE-EFFECTS?
PRAMIPEXOLE/ROPINIROLE/ROTIGOTINE
SIDE-EFFECTS? Impulse disorders (>>>than Levodopa, MOST likely) Sudden onset of sleep Hypotension (postural- treat w/ Midodrine->Fludrocortisone)
LEVODOPA
Whys is carbidopa/benserazide added?
LEVODOPA- SIDE-EFFECTS?
Whys is carbidopa/benserazide added?
Prevents breakdown of levodopa before it crosses into the brain
LEVODOPA- SIDE-EFFECTS?
Impulse disorders: gambling/binge eating/hypersexuality
Sudden onset of sleep (treat w/ modafinil)
Red urine
PARKINSONS DISEASE- FIRST-LINE TREATMENT
Motor symptoms decrease quality of life?
Motor symptoms does NOT decrease quality of life?
Motor symptoms decrease quality of life?
-Levodopa+Carbidopa/Benserazide
Motor symptoms does NOT decrease quality of life?
- Levodopa
- Non-ergot-derived dopamine-receptor (pramipexole, rotigotine)
- Monoamine-oxidase-B-inhibitors (rasagilin/selegiline)
PARKINSONS
Alleviated by?
Alleviated by? Increasing amounts of dopamine
INCREASED ACETYLCHOLINE-> PARASYMPATHETIC SIDE-EFFECTS?
Symp- fight/flight
Parasymp- rest/digest
DUMB BELS Diarrhoea Urinary Incontinence Muscle Weakness Bradycardia Bronchospasms Emesis Lacrimation Salivation
Stop treatment, treat the dehydration before reinitiating and amend the dose if need be
DEMENTIA- TREATMENT
MILD-MODERATE DEMENTIA? AChEIs (and side-effects)
MODERATE-SEVERE DEMENTIA?
AGGRAVATION TREATED W/?
MILD-MODERATE DEMENTIA? AChEIs (and side-effects)
Donepezil- neuroleptic malignant syndrome
Rivastigmine- GI side-effects (less in transdermal formulation)
Galantamine- S-J syndrome (skin reaction, rash)
MODERATE-SEVERE DEMENTIA?
Memantine
AGGRAVATION TREATED W/?
Benzodiazepine/Antipsychotics
DEMENTIA
Alleviated by?
Alleviated by? Increasing amount of acetylcholine
LITHIUM- SIDE-EFFECTS/INTERACTIONS
NOTE IN LITHIUM OD, HYPERNATRAEMIA is present, be careful, bit like digoxin OD, flip it
Hyponatraemia (higher risk of toxicity)- LOOP/THIA (almost all hypo side-effects because of MOA inhibition of Na+/K+/2Cl- transporter)
Salt Imbalance
Serotonin Syndrome (SSRIs, Tramadol)
Extrapyramidal S-E (Antiemetics, Antipsychotics)
QT Prolongation (Macrolides)
Renally Cleared Drugs (NSAIDs- Ibuprofen L, risk of toxicity)
Reduced Seizure Threshold (Tramadol)
Hypokalaemia (diuretics (loop/thiazide), insulin, laxative_
LITHIUM- SIDE EFFCETS?
Thyroid disorder Nephrotoxicity Rhabdomyolysis QT prolongation Benign Intercranial Hypertension (persistent headache and visual disturbance) 1st Trimester- teratogenic
LITHIUM- sick+tremor
THERAPEUTIC RANGE?
ACUTE EPISODE TARGET?
MEASURING LEVELS?
SIGNS OF TOXICITY?
THERAPEUTIC RANGE?
0.4-1.0mmol/L
ACUTE EPISODE TARGET? acute episodes/relapse/sub-syndromal symptoms
0.8-1.0mmol/L
MEASURING LEVELS?
12hours after a dose
Weekly till stable->/3 months for year 1->/6months after that
BUT 65+, /3MONTHS
SIGNS OF TOXICITY? REVeNGe Renal Impairment- incontinence Extrapyramidal- tremor Visual- blurred vision Nervous System Disorder- confusion+restlessness GI Disorder- D&V
BIPOLAR DISORDER- TREATMENT
ACUTE?
PROPHYLAXIS? CSL
ACUTE?
Benzodiazepine (Lorazepam) helps w/ initial symptoms
Antipsyschotics (ROQ- Risperidone, Olanzapine, Quetiapine) L? +in Lithium OR Sodium Valproate
PROPHYLAXIS?
Carbamazepine
Sodium Valproate
Lithium
BIPOLAR DISORDER?
BIPOLAR DISORDER?
Extreme fluctuation between manic (overactive/excitability) & depressive (reclusive/lethargic) phases
EPILEPSY- BREASTFEEDING, BABIES
MONOTHERAPY vs COMBINED?
HIGH PRESENCE IN MILK?
RISK OF DROWSINESS?
WITHDRAWAL EFFECTS- Mother suddenly stops breast-feeding?
MONOTHERAPY vs COMBINED?
Monotherapy- breast-feeding encouraged
Combined therapy/RF- specialist advice
HIGH PRESENCE IN MILK? PELZ Primidone Ethosuximide Lamotrigine Zonisamide
RISK OF DROWSINESS? BP2
Benzodiazepine
Phenobarbital
Primidone
WITHDRAWAL EFFECTS? BP2L Benzodiazepine Phenobarbital Primidone Lamotrigine
*BONUS:
Monitor infants for: sedation, feeding difficulties, weight gain and developmental milestones
FOLIC ACID IN PREGNANCY
LOW RISK OF NEURAL TUBE DEFECTS?
HIGH RISK OF NEURAL TUBE DEFECTS?
LOW RISK OF NEURAL TUBE DEFECTS?
400mcg OD, before conception+till week 12 pregnancy
HIGH RISK OF NEURAL TUBE DEFECTS? PEDS Previous Epileptic Diabetes Sickle cell disease 5mg OD, before conception+till week 12 pregnancy
BUT SICKLE CELL DISEASE IS THROUGHOUT!! (POM btw)
EPILEPSY- PREGNANCY
4 KEY POINTS?
4 KEY POINTS?
Folic acid reduces risk of neural tube defects in first trimester
Vitamin K injection administered at birth to minimize risk of neonatal haemorrhage
Riskiest drug: Sodium Valproate (PPP)
Topiramate: Cleft Palate
EPILEPSY- DRIVING
5 RULES
STOP…
First unprovoked/isolated fit?
Established epilepsy?
Medication change/withdrawal
X drive for how long after last dose?
Seizure ocurs then..?
5 RULES?
Stop ASAP+inform DVLA
First unprovoked/single isolated: 6 months ban
Established epilepsy: 1 year seizure-free, no impact on consciousness (+no history of unprovoked)
Medication change/withdrawal:
Should not drive for 6 months after last dose
Seizure occurs: License revoked for 1 year, but early relicense if treatment has been reinstated for 6 month+seizure-free
PHENYTOIN
THERAPEUTIC RANGE?
SIGNS OF TOXICITY?
THERAPEUTIC RANGE?
10-20mg/L
SIGNS OF TOXICITY? SsNA()tCH(e)D-V Slurred Speech Nystagmus Ataxia Confusion Hyperglycaemia Double Vision
CARBAMAZEPINE
THERAPEUTIC RANGE?
SIGNS OF TOXICITY?
THERAPEUTIC RANGE?
4-12mg/L (Carb, 4 letters, full 12 kind of)
SIGNS OF TOXICITY? HANDBAG Hyponatraemia Ataxia Nystagmus Drowsiness Blurred Vision Arrhythmias GI Disturbances
ANTI-EPILEPTIC SIDE-EFFECTS
HYPERSENSITIVITY? CP3La
SKIN RASH?
BLOOD DYSCRASIA? C.VET.PLZ
EYE DISORDER? VT
ENCEPHALOPATHY?
RESPIRATORY DEPRESSION? GP
HYPERSENSITIVITY? CP3La Carbamazepine Phenytoin Phenobarbital Primidone Lamotrigine
SKIN RASH?
Lamotrigine->Steven-Johnson syndrome
BLOOD DYSCRASIA? C.VET.PLZ Carbamazepine Valproate Ethosuximide Topiramate Phenytoin Lamotrigine Zonisamide
EYE DISORDER? VT
Vigabatrin (reduced visual field)
Topiramate (secondary glaucoma)
ENCEPHALOPATHY?
Vigabatrin
RESPIRATORY DEPRESSION? GP
Gabapentin
Pregabalin
ANTI-EPILEPTIC SIDE-EFFECTS
CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? DH^2BV
CARBAMZEPINE ONLY?
PHENYTOIN ONLY?
SODIUM VALPROATE ONLY?
CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? DH^2BV Depression+Suicide Hepatotoxicity Hypersensitivity Blood Dyscrasia Vitamin D Deficiency (bone pain)
CARBAMZEPINE ONLY?
Hyponatraemia+Oedema
PHENYTOIN ONLY?
Coarsening Appearance Facial Hair
SODIUM VALPROATE ONLY? PPP (Pregnancy Prevention Programme key)
Pancreatitis
Teratogenic
CYP450 ENZYME
Induces?
Inhibits?
Induces? causes enzyme to work quicker, decreases conc. of other X drug
Inhibits? causes enzyme to work slower, increases conc. of other X drug
ANTI-EPILEPTIC INTERACTIONS
CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? HIGH-RISK DRUGS, MUST KNOW IT ALL
CARBAMAZEPINE ONLY?
PHENYTOIN ONLY?
CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? HIGH-RISK DRUGS, MUST KNOW IT ALL
Hepatoxicity: amiodarone, itraconazole, macrolides, alcohol
CYP inducer (CPPheno) inhibitor (Sodium Valproate)
Drugs that lower seizure threshold: Q-TTie! Quinolones (cipro, levo), Tramdaol, Theophylline
CARBAMAZEPINE ONLY? Hyponatraemic drug (SSRI, diuretics)+oedema
PHENYTOIN ONLY?
Anti-folates (Methotrexate, Trimethoprim)
ANTI-EPILEPTICS 3 CATEGORIES most to least severe
CATEGORY 1? CP3
CATEGORY 2? CL-VOP
CATEGORY 3? BEG-LePre
CATEGORY 1? Must be brand-specific CP3 Carbamazepine Phenobarbital Phenytoin Primidone
CATEGORY 2? Use clinical judgement+patient's factors, CL-VOP Clobazam Clonazepam Lamotrigine Oxcarbazepine Perampanel Rufinamide Topiramate Valproate Zonisamide
CATEGORY 3? Unnecessary, Bob's your uncle! BEG-LePre Brivaracetam Ethosuximide Gabapentin Lacosamide Levetiracetam Pregabalin Tiagabine Vigabatrin
STATUS EPILEPTICUS? >5mins seizure
TREATMENT
> 5mins?
> 25mins?
> 45mins?
Community/Resus not available?
> 5mins?
- IV lorazepam (repeat after 10mins (15) if seizure L) preferred
- IV diazepam (high risk of thrombophlebitis+absorption too slow!)
> 25mins? PFP
-Phenytoin/Fosphenytoin/Phenobarbital
> 45mins? TMP
Anaesthesia w/..
-Thiopental/Midazolam/
Propofol (unlicensed indication)
Community/Resus not available?
-Rectal Diazepam/Buccal Midazolam
GENERALISED SEIZURES- 1st LINE & 2ND LINE
TAM
TONIC-CLONIC/ATONIC/TONIC?
ABSENCE?
MYOCLONIC?
TAM
TONIC-CLONIC/ATONIC/TONIC?
1) Sodium Valproate 2) Lamotrigine
ABSENCE?
1) Ethousixime or sodium valproate (valp if high risk of generalised tonic-clonic) 2) Lamotrigine
MYOCLONIC?
1) Sodium Valproate 2) Topiramate OR Levetiracetam
ATONIC?
1) Sodium Valproate 2) Lamotrigine
TONIC?
1) Sodium Valproate 2) Lamotrigine
Don’t give SV in prenmenopause
FOCAL SEIZURES
1ST LINE?
2ND LINE?
1ST LINE?
CL
Carbamazepine/Lamotrigine
2ND LINE?
SLO- Sodium Valproate/Levetiracetam/Oxcarbazepine
EPILEPSY
2 TYPES OF SEIZURES?
FOCAL
GENERALISED
How long to be on an antidepressant after remission?
6 months, after those ‘4 weeks.’
AVOID CYCLIZINE IN PREGNANCY!
Miss U, 73 years old is new to the practice. You are currently conducting a meds
reconciliation from her previous practice notes. From the notes, you can see that she has
been stabilised on a brand of Lithium Citrate for 20 years, and her bloods from the last 3
years all show Lithium being in range. She also has her annual secondary care mental health
review with the psychiatry team.
How often should Miss U come in for monitoring for her Lithium?
. 3 monthly
3 MONTHS ELDERLY BRUH!
Mr L, 58 years old has come into the practice today to see his regular GP. Mr L has recently
been experiencing pain in his back. Below is the list of medication Mr L is currently taking.
▪ Priadel 400mg tablets
▪ Levothyroxine 100mg tablets
▪ Olanzapine 10mg tablets
What would be the least suitable analgesic to prescribe, considering Mr L’s
medication?
NSAIDs, lithium
Ibuprofen increases the concentration of Lithium. Manufacturer advises monitor and adjust dose.
Mr S has had Parkinson’s disease for 3 years now and is on Co-Beneldopa to help manage
his symptoms. Unfortunately, today he has also been diagnosed with Dementia.
Which of the following drugs would be the most appropriate for him to be put on?
Rivastigmine
DULOXETINE DRUG CLASS?
SNRI
Which of the following drugs below has both opioid agonist and antagonist properties?
BUPRENORPHINE
Which of the following antidepressants drugs can increase the risk of bleeding?
SERTRALINE
How many weeks can it take for Buspirone to work?
2 weeks
How long should a patient receive an anti-psychotic drug before it is deemed as being
‘ineffective’?
4-6 weeks
Over how many weeks should the dose of Clozapine be reduced to avoid the risk of rebound
psychosis?
1-2 weeks
Mrs K Alory comes into the pharmacy to collect her monthly repeat prescription of
medications. You are chatting away to her and notice that she’s not her usual self and ask if
she is okay. She informs you that she has been putting on weight recently and unsure why.
She is not eating any more than normal and is exercising the same amount and believes it
may be down the medications.
Which of the medications below is likely to have caused Mrs K Alory’s weight gain?
PIZOTIFEN
methylphenidate weight?
loss, loss of appetite
Which of the following opioids below is likely to exert it affect by being a mu-receptor
agonist, and also enhancing serotonergic and adrenergic pathways?
tramadol
LITHIUM COUNSELLING?
Patients should be advised to report signs and symptoms of lithium toxicity, hypothyroidism,
renal dysfunction (including polyuria and polydipsia), and benign intracranial hypertension
(persistent headache and visual disturbance). Maintain adequate fluid intake and avoid dietary
changes which reduce or increase sodium intake. Manufacturer advises effective contraception
during treatment for women of child bearing potential
Mr PD, a 67-year-old who has been admitted to your ward for routine surgery had a past
medical history of Parkinson’s disease and hypertension. He currently takes Madopar 250mg
TDS and Amlodipine 5mg OM.
Mr PD develops dysphagia post-operatively and a BG tube is inserted to facilitate
enteral feeding and drug administration. Which of the following statements would be
most appropriate for optimising Mr PD’s Madopar therapy?
Mr R’s Madopar® capsules should be switched to the same dose of Madopar®
dispersible tablets for administration via the NG tube
If dispersible tablets are available, there is no need for opening capsules. This will also become
off-label use.
A drug has both opioid agonist and antagonist properties. Sublingually, it is an effective
analgesic for 6-8 hours. Its effects are only partially reversed by naloxone hydrochloride.
Which of the following is the drug most likely to be?
BUPRENORPHINE
A drug indicated in the treatment of epilepsy and due to the long half-life and can be given
once daily.
Which of the following is the drug most likely to be?
Phenobarbital
long half life
OD dosing
hyponatraemia, encourages sodium absorption+lithium
SSRI LONGEST HALF LIFE?
FLUOXETINE
DRUG WITH LEAST ANTICHOLINERGIC SIDE-EFFECTS?
MIRABEGRON
TROSPIUM ALSO USED BRUHHHH
methadone, contraceptive, antidepressant to give?
is amitriptyline safe? minor cns effects?
codeine, maximum/day?
240mg
PHENYTOIN+TRIMETHOPRIM?
both anti-folate, don’t take together!!!
side-effects of procyclidine?
blurred vision
constipation
drowsiness
urinary retention
NOT YELLOW VISION
NOT an enzyme inducer?
levetiracetam
A dose of 100 mg fluphenazine (deconoate) once every two weeks is equivalent to 160 mg once every two weeks of this drug in its deconoate form
flupentixol?
Meniere’s disease?
PROCHLORPERAZINE/CINNARIZINE/CYCLIZINE/PROMETHAZINE
meniere disease?
prochlo
licensed treatment for a patient who has not responded to non-pharmacological
interventions to manage the behavioural and psychological symptoms of dementiagapa
flupentixol
Acute kidney injury?
gabapentin
PD REVIEW?
EVERY 6-12 MONTHS
DISulfiram with alcohol?
nausea, flushing, palpitations, arrhythmias, hypotension, respiratory depression, and coma
varenicline depression?
stop
gp quickly?
best motion sickness?
HYO HYDRO
hypersalivation w/ clozapine treatment?
hyoscine hydrobromide
LITHIUM MONITORING?
12 hours post-dose
weekly till stable
then /3 months for year 1
then /6 months after that
65+? ALWAYS /3 MONTHS IRRESPECTIVE
CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE INTERACTIONS?
Hepatoxicity: amiodarone, itraconazole, macrolides, alcohol
CYP inducer (CPPheno) inhibitor (Sodium Valproate)
Drugs that lower seizure threshold: Q-TTie! Quinolones (cipro, levo), Tramdaol, Theophylline
midazolam schedule?
schedule 3
oramorph 10mg/5ml?
schedule 5
oramorph 20mg/ml?
schedule 2
TYPICAL FIRST-GEN ANTIPSYCHOTICS?
CHLOPROMAZINE, LEVOMEPROMAZINE HALOPERIDOL ZUCLOPENTHIXOL PIMOZIDE SULPIRIDE
EPILEPSY
“If a seizure occurs due to a prescribed change or withdrawal of epilepsy treatment, the patient will have their driving license revoked for 1 year; relicensing may be considered earlier if treatment has been reinstated for 6 months and no further seizures have occurred.”
Opioids, missed 3 days or more?
risk of OD
loss of tolerance
need to reduce dsoe
TRIPTAN MEDICATION, NOT LICENSED IN?
PREGNANT/BREASTFEEDING
Naloxone- opioid
Naltrexone- alcohol
PHENYTOIN
FOSPHENYTOIN
CARBAMAZEPINE
OXCARBAZEPINE
PRE-SCREEN FOR?
Test for HLA-B1502 allele in individuals of Han Chinese or Thai origin (avoid unless no alternative—risk of Stevens-Johnson syndrome in presence of HLA-B1502 allele)
offensive drugs?
Smoking and drugs? TACOW
Theophylline Aminophylline Clozapine Olanzapine Warfarin
A distressed patient has come into the hospital after experiencing symptoms of increased
anxiety, aggression, and agitation. The patient only takes ramipril and diazepam regularly. Which
one of the following medications is most likely to be given to the patient
flumazenil, reverses benzos!!
A patient has come into the pharmacy with a headache they have described to be very painful.
They have described it as a sudden severe pain alongside a stiff neck, sensitivity to light and
double vision. What is this patient experiencing
The patient is describing the symptoms of a subarachnoid haemorrhage which is more specifically
differentiated by the stiff neck and the sudden severe onset. This is a medical emergency and the
patient should go straight to A&E.
Mrs Chloe Phenamine has been taking sertraline 100mg daily for the past 6 months. As she has
not seen any improvement, the doctor wants to initiate an alternative treatment. The GP asks
which medication would be most suitable. Which medication is recommended
Failure to respond to initial treatment with an SSRI may require an increase in the dose or switching
to a different SSRI or mirtazapine
A 21-year-old lady has recently been diagnosed with generalised myoclonic seizures. The doctor
would like the advice of the pharmacist on which medication would be most appropriate. Which
medication would be most appropriate
First line treatment for myoclonic seizures is Sodium Valproate. However, due to the patient’s
gender and age, being of childbearing potential, initiating treatment with Sodium Valproate should
be avoided. Second line treatment is Topiramate and Levetiracetam.
Mr Tim Olol has recently been initiated on Olanzapine for the treatment of schizophrenia. The
patient is due to have a few parameters measured. Which of the following is not a monitoring
requirement of Olanzapine
NOT COGNITIVE!
Monitoring requirements for people taking antipsychotics includes body weight, U&Es, FBCs, blood
lipids, blood glucose levels, pulse, blood pressure, ECGs, prolactin levels, and LFTs
PROALCTIN MONITORING?
START
6 MONTHS
YEARLY
A panicked customer has come into the pharmacy saying that someone has been having a
seizure at the bus stop nearby. The pharmacist has timed the seizure and it has exceeded 5
minutes. Which medication is the paramedic most likely to administer to the patient on arrival?
As the seizure has lasted over 5 minutes, the patient is experiencing status epilepticus. Where
facilities for resuscitation are not immediately available, diazepam can be administered as a rectal
solution or midazolam oromucosal solution can be given into the buccal cavity.
Mr Hernia, a 75-year-old man is currently in late stages of Parkinson’s disease and is
experiencing severe “off periods”. The consultant will want to initiate them on a potent
dopamine-receptor agonist administered parenterally by subcutaneous injection. Which
medication is being referred to
Apomorphine is a consultant led potent dopamine-receptor agonist which can be helpful in dealing
with ‘off’ episodes with levodopa treatment. It is administered parenterally by subcutaneous
injection or infusion
Mr Mike Conazole has been admitted to hospital after breaking his leg falling off a horse. He has
been suffering with severe pain for which the doctor is prescribing morphine sulphate to help
with that. Mr Conazole would like to know what sort of side-effects he should expect. Which
side-effect is least likely to occur with morphine
Opiates act on the mu-pathway causing dry mouth, constipation, CNS depression, nausea and
vomiting, hypotension, urinary retention, and miosis (pupil constriction)
NOT ANXIETY!
Mrs Laci Dipine has been taking codeine for chronic back pain for a few months but that is not
insufficient in terms of managing her pain levels. The doctor has decided to move her onto a
moderate opiate, tramadol. The patient would like to know what the side-effects for this
medication are. Which of the following is not a side-effect of tramadol?
NOT HYPERTENSION
Counselling points of tramadol includes reduced seizure threshold, increased risk of bleeding,
psychiatric disorders, and serotonin syndrome. hypotension
Miss Val Sartan a 26-year-old married lady has been advised to be started on anti-epileptic
therapy after being diagnosed with tonic-clonic seizures. Which of the following anti-epileptics
would be the least suitable for the patient?
Sodium valproate is highly teratogenic and must not be used in females of childbearing potential
unless the conditions of the Pregnancy Prevention Programme are met, and alternative treatments
are ineffective or not tolerated.
The pre-registration student was selling a packet of Sumatriptan over-the-counter and was
unsure as to when the medication was contraindicated. Which of the following scenarios would
mean that supplying sumatriptan should be avoided
HYPERTENSION
Sumatriptan works by causing vasoconstriction which leads to reduced pain. Therefore, patients
with cardiovascular diseases and hypertension should avoid the use of sumatriptan
Mr Olli Stat has been diagnosed with Parkinson’s disease. The patient has had their initial
assessment and their motor symptoms has not affected their quality of life. Which medication
would not be included in the patient’s treatment plan
Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be
prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole,
ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).
Entacapone is a COMT Inhibitor.
ENTACAPONE IS ONLY FOR SIDE-EFFECTS, WITH OPTIMAL LEVODOPA
The following benzodiazepines have a legal driving limit: Clonazepam, Oxazepam, Lorazepam,
Diazepam, Flunitrazepam and Temazepam (COLD FeeT).
Miss Remi Pril, a 23-year-old patient has been diagnosed with depression and is being prescribed
with Sertraline. The patient is due to have counselling on the medication. Which of the following
points is least likely to be included in the counselling session
GASHBIQ!!!
Sertraline can cause insomnia if taken at night. Therefore, the medication should be taken in the
morning.
A 24-year-old man has had a seizure on the wards which has now lasted 13 minutes. The patient
has already been administered IV Lorazepam, but the seizure has not halted. What is the next
step to take
Seizures lasting longer than 5 minutes should be treated urgently with intravenous lorazepam
(repeated once after 10 minutes if seizures recur or fail to respond). Intravenous diazepam is
effective, but it carries a high risk of thrombophlebitis
STATUS EPILEPTICUS, >5mins
community?
rectal diazepam
buccal midazolam
A patient has been taking Rivastigmine for the treatment of dementia for the past 3 weeks. The
patient has complained of nausea, diarrhoea, dehydration, and gastrointestinal discomfort since
taking the medication. What is the most appropriate action for this patient
Treatment should be interrupted if dehydration resulting from prolonged vomiting or diarrhoea
occurs and withheld until resolution. Dose should be amended if necessary. Transdermal
administration is less likely to cause side-effects.
Mr Bud Esonide, a 45-year-old patient being initiated on Lithium has been advised to have a
consultation with the pharmacist. The patient had heard that it was possible for him to
overdose on the medication. Which of these symptoms do not create a cause for concern
Signs of toxicity includes vomiting, diarrhoea, visual disturbances, polyuria, muscle weakness, fine
tremor increasing to coarse tremor, confusion, drowsiness, restlessness, incontinence,
hypernatremia, seizures, and arrhythmias
NOT CONSTIPATION!
Mr Esonide came into the hospital after 2 weeks of taking medication as the pharmacist had told
him to seek medical advice if he experienced any nausea and vomiting due to toxicity. The
doctor would like to prescribe an anti-emetic and asked the pharmacist if there was any that
should be avoided. Which anti-emetic should be avoided from the list below
Domperidone increases the risk of QT-prolongation when given with lithium. Manufacturer advises
avoid
AMFETAMINES?
Amfetamines in overdose can cause wakefulness, excessive activity, paranoia, hallucinations, and
hypertension followed by exhaustion, convulsions, hyperthermia, and coma
A pregnant lady has come into the pharmacy as she has been experiencing severe nausea and
vomiting. As nothing can be given to her over the counter, the pharmacist referred the patient
to the GP to be prescribed an anti-emetic. What is first line to be prescribed for the lady
If vomiting is severe in pregnancy, short-term treatment with promethazine may be required.
4 years later, Mr Oxaban has now been taken off carbamazepine, and has been advised to not
drive in accordance with the DVLA’s regulations. How long should the patient refrain from
driving for?
The DVLA recommends that patients should not drive during medication changes or withdrawal of
antiepileptic drugs, and for 6 months after their last dose
The preregistration student was amazed to hear that certain medications can alter the colour of
a patient’s urine. Which of the following medications do not cause a change in urine colour?
Amitriptyline has been known to turn urine a green-blue colour. COMT Inhibitors such as
entacapone and tolcapone may discolour urine to orange-brown. Levodopa will colour urine red
A patient using methadone to treat substance misuse is being converted to buprenorphine and
naloxone therapy by the consultant. What might be the for this change in medication
A combination preparation containing buprenorphine with naloxone can be prescribed for patients
when there is a risk of dose diversion for parenteral administration
A patient has come in with a prescription for amitriptyline as a new medication. The patient is on
a lot of medication already, most of which, the amitriptyline will interact with. Which of the
following medications from his list is the only one that will not interact with the amitriptyline
Amitriptyline is affected by CYP 450 Enzyme inhibitors and inducers. Carbamazepine, an enzyme
inducer, decreases the exposure to amitriptyline as well as adding to the hyponatraemic affect. Both
amitriptyline and hyoscine can cause antimuscarinic effects. Both amitriptyline and candesartan can
increase the risk of hypotension. Both amitriptyline and pregabalin can have CNS depressant
effects, which might affect the ability to perform skilled taskS
PERICYAZINE LEAST EPSE!
TAMOXIFEN INTERACTION?
FLUOXETINE+PAROXETINE
. Mr Mo Clobemide has come into the pharmacy with a cold and wanted to buy some
pseudoephedrine over the counter. After checking the patients PMR, the pharmacist has
decided to refuse the sale. Which medication was the reason for the refusal of this sale
– Tranylcypromine as well as other MAO inhibitors should not be given with pseudoephedrine.
Pseudoephedrine is predicted to increase the risk of hypertensive crisis when given with MAO
inhibitors.
DO NOT GIVE MAOI WITH?
PHENYLEPHRINE/PSEUDOEPHEDRINE
A patient has come into the hospital for an elective hip replacement surgery. Prior to the
surgery, the patient is experiencing nausea and vomiting alongside anxiety and a fast heart rate.
Which anti-emetic would you recommend being prescribed prior to the surgery?
Lorazepam is used in the case of anticipatory nausea and vomiting related with anxiety
A patient has come into the pharmacy with a prescription for clarithromycin. On the
prescription there was also an anti-emetic prescribed. You have decided to only dispense the
antibiotic and refer the patient back to the GP for the anti-emetic due to an interaction. Which
anti-emetic was likely to have been prescribed to cause this interaction
Both Macrolides and Domperidone interact to cause QT interval prolongation
A patient has come into the pharmacy after experiencing some muscle pain from a fall. The
patient has requested to buy some ibuprofen capsules to alleviate the pain. On checking the
patient’s medical records, they also take sertraline. Which interaction is likely to occur
SSRI+NSAID? GI BLEED!
SSRI, NSAID, BLEED!
AMIODARONE+TCA?
QT prolongation
. After the hospital admission, Mr Thium was discharged and advised to continue taking Lithium
400mg twice daily. What is the target serum concentration of Lithium for the patient for
maintenance
0.4-1 AFTER?
VIGABATRIN?
visual defects, yes sir
UNPROVOKED SEIZURE?
Patients who have had a first unprovoked epileptic seizure or a single isolated seizure must not drive for 6 months; driving may then be resumed, provided the patient has been assessed by a specialist as fit to drive and investigations do not suggest a risk of further seizures.
sertraline+tramadol?
serotonin syndrome
sertraline+ibuprofen?
bleed
lithium+amitriptyline?
neurotoxicity
A 55-year-old woman, with breast cancer and taking tamoxifen, is prescribed this antidepressant for menopausal symptoms as per the BNF recommended dose. It is not licensed for this indication.
Venlafaxine is used for menopausal symptoms, but it is not licensed for this indication. Fluoxetine and paroxetine are also used but not for those women on tamoxifen (due to interaction).
Venlafaxine is used for menopausal symptoms, but it is not licensed for this indication. Fluoxetine and paroxetine are also used but not for those women on tamoxifen (due to interaction).
ENZYME INDUCING ANTI EPILEPTICS?
CP3T
Carbamazepine. Eslicarbazepine acetate. Oxcarbazepine. Perampanel (at a dose of 12 mg daily or more). Phenobarbital. Phenytoin. Primidone. Rufinamide. Topiramate (at a dose of 200 mg daily or more).
LITHIUM+
ANTIPSYHCO
SSRI
MAOI
SSRI- QT prolongation
MAOI- serotonin syndrome
L
MAYBE just clozapine?
LITHIUM+ANTIDEPRESSANTS?
SERTRALINE- SEROTONIN SYNDROME
CITALOPRAM- QT PROLONGATION
VALSARTAN
FALLS
menopausal symptoms antidepressant?
venlafaxine!
antiepileptic kidney stones?
topiramate!
Mrs AK is due an endoscopy in two days’ time. She is extremely anxious about the procedure and the doctor asks for your advice about which benzodiazepine would be most appropriate to give for conscious sedation. Which of the following is the most appropriate choice?
midazolam 2.5mg subcutaneously 5-10 minutes pre-procedure, repeated if necessary
zopiclone max duration???
6 months
LITHIUM+BENDROFLUMETHIAZIDE???
HYPONATARAEMIA?!hmm
• If a person develops moderate or severe bipolar depression and is already taking lithium, check their plasma lithium level. If it is inadequate, increase the dose of lithium; if it is at maximum level, add either fluoxetine combined with olanzapine or add quetiapine, depending on the person’s preference and previous response to treatment.
- If the person prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to lithium.
- If there is no response to adding fluoxetine combined with olanzapine, or adding quetiapine, stop the additional treatment and consider adding lamotrigine to lithium.
• If a person develops moderate or severe bipolar depression and is already taking lithium, check
their plasma lithium level. If it is inadequate, increase the dose of lithium; if it is at maximum
level, add either fluoxetine combined with olanzapine or add quetiapine, depending on the
person’s preference and previous response to treatment
