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pre reg Thammis cards > CNS > Flashcards

CNS Flashcards

1
Q

what is the first line treatment for focal seizures

A

carbamazepine OR lamotrigine

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2
Q

what is the second line treatment for focal seizures

A

oxcarbamazepine, Levetiracetam or sodium valproate

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3
Q

MHRA warnings for antiepileptic drugs

A
  1. risk of suicidal thoughts and behaviour
    - seek advice if change in mood or thoughts
    - would need to stop or switch AED
  2. switching between brands = ADR/ loss of seizure control
    - dependent on category if brands can be switched
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4
Q

what are the categories and drugs for antiepileptic drugs

A

category 1: carbamazepine, phenobarbital, phenytoin, primidone (CPPP)
MAINTAIN ON BRAND

category 2: clobazam, clonazepam, lamotrigine, oxcarbamazepine, topiramate, sodium valproate
- use clinical judgement for brand maintenance

category 3: gabapentin, ethosuximide, lacosamide, levetiracetam, pregabalin, vigabatrin
- dont need to maintain on specific brand

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5
Q

What are the 1st and 2nd line treatments for different types of generalised seizures

A

tonic-clonic: 1st line- sodium valproate, 2nd line: lamotrigine

absence: 1st line- ethosuximide/ sodium valproate, 2nd line: lamotrigine
myoclonic: 1st line- sodium valproate, 2nd line: topiramate/ levetiracetam
atonic: 1st line- sodium valproate, 2nd line: lamotrigine
clonic: 1st line- sodium valproate, 2nd line: lamotrigine

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6
Q

treatment of status epilepticus in hospital and community

A

hospital
seizures lasting longer than 5 minutes: IV lorazepam or IV diazepam (risk of thrombophelbitis) -> can be repeated after 10 minutes if persists

seizure continuing for more than 25 minutes: IV phenytoin, fosphenytoin or phenobarbital

seizure continuing for more than 45 minutes: thiopental, midazolam or propofol

Community/ resus not available
buccal midazolam OR rectal diazepam

add on drugs:
pyridoxine if pyridoxine deficiency
thiamine if alcohol abuse

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7
Q

which AED can cause steven johnson syndrome

A

lamotrigine

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8
Q

what AED can cause hypersensitivity syndrome

A

carbamazepine, phenytoin, phenobarbital, primidone, lamtrogine (CPPPL - category 1 plus lamtorigine)

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9
Q

what AED causes blood dyscrasias

A

C.VET.PLS

carbamazepine, vigabatrin, ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide

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10
Q

what AED causes eye disorders

A

vigabatrin (reduced visual field)

topiramate (secondary glaucoma)

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11
Q

signs of phenytoin toxicity and the therapeutic range

A

therapeutic range: 10-20mg/L

signs of toxicity: slurred speech, nysatgmus, ataxia, confusion, hyperglycaemia, double/ blurred vision

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12
Q

signs of carbamazepine toxicity and therapeutic range

A

therapeutic range: 4-12mg/l

signs: hyponatraemia, ataxia, nystagmus, drowsiness, blurred vision, arrhythmia, GI disturbance

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13
Q

what AED have high risk in pregnancy and what should be given to reduce risks

A

highest risk: valproate
high risk: carbamazepine, phenytoin, phenobarbital, primidone, lamotrigine
topiramate in 1st trimester can cause cleft palate

reduce risk:
folic acid 5mg in 1st trimester
vitamin K injection in newborn

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14
Q

which AED are CYP inducers and inhibitors and what do each interact with

A

CYP inducers: carbamazepine, phenytoin, phenobarbital
- interacts with warfarin, HRT, hypothyroid drugs (lithyronine and levothyroxine) = decreases the concentration

CYP inhibitors: sodium valproate
- interacts with other AED = increases the concentration

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14
Q

which AED are CYP inducers and inhibitors and what do each interact with

A

CYP inducers: carbamazepine, phenytoin, phenobarbital
- interacts with warfarin, HRT, hypothyroid drugs (lithyronine and levothyroxine) = decreases the concentration

CYP inhibitors: sodium valproate
- interacts with other AED = increases the concentration

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15
Q

what drugs lower the seizure threshold

A

quinolones, tramadol, theophylline

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16
Q

hepatotoxic drugs that interact with carbamazpine, phenytoin and sodium valproate

A

amiodarone, itraconazole, macrolides, alcohol

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17
Q

interactions of phenytoin

A
  • antifolates (trimethoprim, MTX)
  • phenytoin concentration decreased by enzyme inducers
  • phenytoin concentration increased by enzyme inhibitors
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18
Q

therapeutic range for lithium

A

normal: 0.4-1mmol/l

acute episode: 0.8-1mmol/l

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19
Q

what is the management for dementia

A

mild- moderate: acetylcholinesterase inhibitors
donepezil
galantamine
rivastigmine

moderate- severe: NMDA antagonist
memantine

aggression:
benzodiazepine/ antipsychotics

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20
Q

what is the MHRA alert for antipsychotics in elderly patients with dementia

A

risk of stroke and death- review every 6 weeks

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21
Q

what are the side effects of acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine

A

donepezil: neuroleptic syndrome
rivastigmine: GI side effects- reduced with use of patch
galantamine: steven johnson syndrome - stop as soon as rash seen

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22
Q

what are the side effects of increased acetylcholine

A 
diarrhoea
urinary incontinence
muscle weakness
bradycardia
bronchospasms
emesis
lacrimation (tears)
saliva increased
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23
Q

what are the treatment pathways for parkinsons disease

A

motor symptoms which affect quality of life:
levodopa + benserazide/ carbidopa

motor symptoms which do NOT affect quality of life:
levodopa OR
non-ergot derived dopamine agonists OR
MAOB inhibitors

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24
Q

side effects of levodopa and how these would be managed

A

impulse disorders -> reduce dose gradually/ withdraw until subsides

sudden onset of sleep -> modafinil

red urine - normal

end of dose deterioration -> Switch to modified release preparations

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25
Q

examples of ergot derived and non-ergot derived dopamine agonists and side effects of these classes

A

NON-ERGOT DERIVED:
pramipexole, ropinorole, rotigotine
side effects: impulse disorder, sudden sleep, hypotension

ERGOT DERIVED: 
cabergoline, bromocriptine
side effects: fibrotic reactions
pulmonary: SOB, chest pain cough 
pericardial: chest pain,
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26
Q

examples of MAOB inhibitors and counselling points/ side effects

A

resagiline, selegeline

  • hypertensive crisis if given with pseudoephedrine/ phenylephrine/ nasal OTC products
  • interaction with tyramine rich foods
27
Q

additional management options for dyskinesia/ motor fluctuations if levodopa alone not sufficient

A

non-ergot derived dopamine agonists
COMT inhibitors
MAOB inhibitors
ergot derived dopamine agonists if not responding to non-ergot derived

28
Q

examples of COMT inhibitors and side effects

A

entacapone: red brown urine
tolcapone: hepatotoxic- report signs of liver toxicity

both increase sympathetic side effects - increase CVD risk, interaction with sympathomimetics

29
Q

MHRA warning for antipsychotics in elderly with dementia

A

risk of stroke and death

- review every 6 weeks

30
Q

indication, interaction, monitoring and side effects of clozapine

A

indication: resistant schizophrenia if not responding to at least 2 antipsychotics (where at least 1 is 2nd generation) for at least 6 - 8 weeks
interaction: agranulocytosis- aminosalicylate, MTX, immunosuppressants…
monitoring: weekly for first 18 weeks, then fortnightly until a year then monthly

side effects: myocarditis- stop if tachycardia, agranulocytosis- report flu symptoms, GI obstruction- refer to A+E if constipation

31
Q

symptoms of neuroleptic malignant syndrome

A 
hyperthermia
muscle rigidity
urinary incontinence 
sweating
tachycardia
32
Q

acute and chronic treatment for anxiety

A

acute: benzodiazepines
chronic: SSRI or propranolol

33
Q

examples of short acting and long acting benzodiazepines

A

short acting: lorazepam, oxazepam
- preferred in liver impairment and elderly

long acting: diazepam, chlordiazepoxide, clobazepam, alprazolam, nitrazepam

34
Q

antidote for benzodiazepines

A

Flumazenil

35
Q

1st line treatment for depression and the safest SSRI in cardiac event and under 17

A

1st line: SSRI
cardiac event: use sertraline
under 17: fluoxetine

36
Q

side effects of SSRI

A

GI disturbances: diarrhoea, vomiting
sexual dysfunction
weight gain/ fluctuations
risk of bleeding: increased with NSAIDs, anticoagulants…
QT prolongation (Especially citalopram/ escitalopram)
insomnia- take in the morning to avoid this

37
Q

interactions of SSRI

A

enzyme inducers
enzyme inhibitors (grapefruit juice)
drugs that cause QT prolongation
drugs that increase bleed risk
drugs that may enhance hyponatraemia (e.g., carbamazepine, diuretics)
drugs that may cause serotonin syndrome (SSRI, MAOI, SNRI, lithium, bupropion, linezolid, TCAs, St Johns wort, anti-nausea medicine, ritonavir)

38
Q

what is serotonin syndrome and the symptoms

A

characterised as a trio of:

  1. Cognitive effects: headache, agitation, hypomania, coma, confusion
  2. Autonomic effects: sweating, hyperthermia, nausea, diarrhoea
  3. Neuromuscular excitation: myoclonus, tremor, teeth grinding

symptoms: confusion, disorientation, high BP, dilated pupils, sweating, shivering, diarrhea, twitches, tachycardia…

39
Q

what are the sedating and non-sedating TCA

A

sedating: amitriptyline, clomipramine, dosulepin, trazadone

less sedating: nortriptyline, imipramine, lofepramine

40
Q

which 2 TCA are dangerous in overdose therefore not prescribed for depression

A

amitriptyline and dosulepin

41
Q

side effects of TCAs

A 
cardiac - QT prolongation
Anti-muscarinic
seizures
hypotension
hallucinations
42
Q

examples of MAO inhibitors and the irreversible one

A

phenelzine - hepatotoxic
isocarboxazid - hepatotoxic
tranylcypromaine (major interaction with clomipramine = FATAL)
moclobemide (irreversible)

43
Q

counselling points for MAOI

A

throbbing headache = hypertensive crisis = discontinue
avoid OTC sympathomimetics e.g., pseudoephedrine and dopaminergics
avoid tyramine rich foods
phenelzine and isocarboxazid = hepatotoxic
avoid abrupt withdrawal

44
Q

explain the washout period before starting MAOI

A

If starting antidepressant after MAOI wait 2 weeks (3 weeks for imipramine and clomipramine)

if starting new MAOI wait 2 weeks (no waiting needed for moclobemide)

if switching from TCA wait 1-2 weeks

if switching from SSRI wait 1 week (5 weeks for fluoxetine and 2 weeks for sertraline)

45
Q

what is the only licenced antidepressant for age 5-17

A

fluoxetine

caution in 5-11

46
Q

what are the 3 types of insomnia and their treatment

A

transient: due to external factors such as work, noise…
treatment: rapidly eliminated hypnotics (1-2 doses given)

short-term: due to emotional or medical illness, may last few weeks or recur
treatment: hypnotic (3 weeks can be given by preferably 1 week) - intermittent usage is advised
melatonin can be used for adults over 55 and jet lag

chronic: due to actual cause such as psychiatric, mental health, drug abuse…
treatment: underlying cause - choose drug that might help with cause plus sleep e.g., clomipramine and mirtazapine can aid sleep

47
Q

caution of benzodiazepines and Z-drugs

A

avoid in elderly due to risk of falls and becoming confused and ataxic
chlormethiazole can be given in elderly as no hangover effect

dental patients can be given diazepam or temazepam before procedure (temazepam preferred due to less hangover effects)

48
Q

side effects of the Z drugs and cautions

A

zopiclone - taste disturbance
zolpidem - GI disturbance
alcohol enhances CNS depressants effects
can cause paradoxical effects (opposite effects)
max 4 weeks use
dependency occurs within 3-14 days of use

49
Q

treatment of ADHD in children and adults

A

CHILDREN OVER 5
1st line: methylphenidate
2nd line: lisdexamfetamine (if above not effective at max dose for 6 weeks)
3rd line: atomoxetine or guanfacine

ADULTS
1st line: methylphenidate or lisdexamfetamine
2nd line: atomoxetine

MR preparations must be BRAND specific

50
Q

side effects and monitoring of methylphenidate, lisdexamfetamine and dexamfetamine

side effects of atomoxetine

A

cardiac: High BP, tachycardia, arrythmia
endocrine: behaviour/ mood change, sleep disorder, decreased appetite, growth retardation, weight loss

monitor: pulse, BP, weight, height, psychiatric symptoms, appetite
at initiation then 6 monthly

atomoxetine: QT interval, hepatotoxic, suicide ideation

51
Q

how is overdose of ADHD medication shown

A
  1. wakefulness, excessive activity, hallucinations, hypertension
  2. tiredness, exhaustion, convulsion, hypothermia, coma
52
Q

management of alcohol dependence

A

based on symptoms

dependence: acamprosate, naltrexone (disulfiram = alternative)
withdrawal: long acting benzo- chlordiazepoxide or diazepam (carbamazepine, clomethiazole = alternative)
delirium: lorazepam

wernickes encephalopathy: thiamine

53
Q

management of nicotine dependence

A

varencicline: avoid in epilepsy, psychiatric illness, CVD

bupropion: avoid in psychiatric illness, seizures and eating disorders
- may cause serotonin syndrome

NRT:
patch (16 hours for pregnant women or if nightmares occur) PLUS
Short term reliever: gum, lozenges, inhalator, spray

54
Q

management of opioid dependence

A 
buprenorphine
less sedating than methadone 
milder withdrawal symptoms
lower risk of overdose 
suboxone given as reversal in case buprenorphine injected

methadone
QT prolongation
volume needs to be titrated

3 or missed doses = refer
naloxone given for overdose

55
Q

how are triptans taken for migraine

A

take at the start of headache not aura

repeat dose can be taken after 2 hours (4 hours for naratriptan) if slight improvement but not fully recovered

56
Q

1st line treatment for acute migraine

A

ibuprofen, aspirin, triptan (sumatriptan drug of choice)

57
Q

what antiemetics can be used in migraines

A

metoclopramide or prochlorperazine or domperidone (UL in under 35kg)

58
Q

Migraine prophylaxis options

A

1st line: propranolol
if CI: nadolol or metoprolol

topiramate can be given if betablocker unsuitable - teratogenic

2nd line: amitriptyline
if not tolerated: less sedating TCA

59
Q

specialist treatment for migraines

A

botox, sodium valproate, pizotifen

60
Q

3 types of headaches and their treatment

A

CLUSTER: unilateral pain around 1 eye
acute treatment: sumatriptan or zolmitriptan
prophylaxis: verapamil, lithium, prednisolone, ergotamine (rare)

TENSION: throbbing bilateral pain - like a tight band around head
acute: paracetamol or ibuprofen

TRIGEMINAL NEURALGIA
sharp, shock like pain around jaw, teeth, mouth
acute: carbamazepine

61
Q

what antiemetics are used and avoided in patient groups: pregnancy, postoperative, perioperative, motion sickness, terminal illness, parkinsons

A

pregnancy: promethazine
postoperative: ondansetron or dexamethasone
perioperative: lorazepam
motion sickness: hyoscine hydrobromide
terminal illness: antipsychotics - haloperidol, levomepromazine
parkinsons: domperidone (avoid metoclopramide)

62
Q

similarities and differences between metoclopramide and domperidone

A

similarities: 10mg TDS

differences:
domperidone - doesnt cross BBB, minimum age = 12 years, max 7 day use, weight must be above 35kg and side effect = QT prolongation

metoclopramide - crosses BBB = central effects, minimum age = 18 years, max 5 day use

63
Q

patient licencing for codeine

A

codeine tablets: above 12 years (avoid if under 18 and had tonsils removed due to sleep apnoea)
codeine linctus: above 18 years
avoid in pregnancy
avoid in ultra rapid metabolisers (Afro-caribbean)

64
Q

CI for strong opioids

A

paralytic ileus, respiratory disease, head injury

65
Q

dose for breakthrough pain, dose adjustments and switching opiates

A

breakthrough: 1/6th to 1/10th of total daily dose every 2-4 hours

dose adjustments: increase by 1/2 to 1/3 each day

switching: reduce dose by 1/2 to 1/3 of equivalent drug and dose

pre reg Thammis cards (8 decks)

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