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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
side effects of levodopa and how these would be managed
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
25
examples of ergot derived and non-ergot derived dopamine agonists and side effects of these classes
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, ```
26
examples of MAOB inhibitors and counselling points/ side effects
resagiline, selegeline - hypertensive crisis if given with pseudoephedrine/ phenylephrine/ nasal OTC products - interaction with tyramine rich foods
27
additional management options for dyskinesia/ motor fluctuations if levodopa alone not sufficient
non-ergot derived dopamine agonists COMT inhibitors MAOB inhibitors ergot derived dopamine agonists if not responding to non-ergot derived
28
examples of COMT inhibitors and side effects
entacapone: red brown urine tolcapone: hepatotoxic- report signs of liver toxicity both increase sympathetic side effects - increase CVD risk, interaction with sympathomimetics
29
MHRA warning for antipsychotics in elderly with dementia
risk of stroke and death | - review every 6 weeks
30
indication, interaction, monitoring and side effects of clozapine
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
symptoms of neuroleptic malignant syndrome
``` hyperthermia muscle rigidity urinary incontinence sweating tachycardia ```
32
acute and chronic treatment for anxiety
acute: benzodiazepines chronic: SSRI or propranolol
33
examples of short acting and long acting benzodiazepines
short acting: lorazepam, oxazepam - preferred in liver impairment and elderly long acting: diazepam, chlordiazepoxide, clobazepam, alprazolam, nitrazepam
34
antidote for benzodiazepines
Flumazenil
35
1st line treatment for depression and the safest SSRI in cardiac event and under 17
1st line: SSRI cardiac event: use sertraline under 17: fluoxetine
36
side effects of SSRI
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
interactions of SSRI
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
what is serotonin syndrome and the symptoms
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
what are the sedating and non-sedating TCA
sedating: amitriptyline, clomipramine, dosulepin, trazadone | less sedating: nortriptyline, imipramine, lofepramine
40
which 2 TCA are dangerous in overdose therefore not prescribed for depression
amitriptyline and dosulepin
41
side effects of TCAs
``` cardiac - QT prolongation Anti-muscarinic seizures hypotension hallucinations ```
42
examples of MAO inhibitors and the irreversible one
phenelzine - hepatotoxic isocarboxazid - hepatotoxic tranylcypromaine (major interaction with clomipramine = FATAL) moclobemide (irreversible)
43
counselling points for MAOI
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
explain the washout period before starting MAOI
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
what is the only licenced antidepressant for age 5-17
fluoxetine | caution in 5-11
46
what are the 3 types of insomnia and their treatment
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
caution of benzodiazepines and Z-drugs
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
side effects of the Z drugs and cautions
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
treatment of ADHD in children and adults
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
side effects and monitoring of methylphenidate, lisdexamfetamine and dexamfetamine side effects of atomoxetine
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
how is overdose of ADHD medication shown
1. wakefulness, excessive activity, hallucinations, hypertension 2. tiredness, exhaustion, convulsion, hypothermia, coma
52
management of alcohol dependence
based on symptoms dependence: acamprosate, naltrexone (disulfiram = alternative) withdrawal: long acting benzo- chlordiazepoxide or diazepam (carbamazepine, clomethiazole = alternative) delirium: lorazepam wernickes encephalopathy: thiamine
53
management of nicotine dependence
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
management of opioid dependence
``` 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
how are triptans taken for migraine
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
1st line treatment for acute migraine
ibuprofen, aspirin, triptan (sumatriptan drug of choice)
57
what antiemetics can be used in migraines
metoclopramide or prochlorperazine or domperidone (UL in under 35kg)
58
Migraine prophylaxis options
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
specialist treatment for migraines
botox, sodium valproate, pizotifen
60
3 types of headaches and their treatment
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
what antiemetics are used and avoided in patient groups: pregnancy, postoperative, perioperative, motion sickness, terminal illness, parkinsons
pregnancy: promethazine postoperative: ondansetron or dexamethasone perioperative: lorazepam motion sickness: hyoscine hydrobromide terminal illness: antipsychotics - haloperidol, levomepromazine parkinsons: domperidone (avoid metoclopramide)
62
similarities and differences between metoclopramide and domperidone
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
patient licencing for codeine
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
CI for strong opioids
paralytic ileus, respiratory disease, head injury
65
dose for breakthrough pain, dose adjustments and switching opiates
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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