CNS Flashcards
DEMENTIA
AIM - Alleviate symptoms by increasing the amount of acetylcholine
NAME 3 ACETYLCHOLINESTERASE INHIBITORS FOR MILD - MODERATE DEMENTIA DUE TO ALZHEIMERS
DONEPEZIL ADV - Neuroleptic malignant syndrome
RIVASTIGMINE ADV - GI SE
GALANTAMINE ADV - Steven-Johnson syndrome
TREATMENT FOR MODERATE - SEVERE DEMENTIA DUE TO ALZHEIMERS
GLUTAMATE RECEPTOR ANTAGONIST
1st LINE -
MEMANTINE
(Use with caution with epilepsy/ history of convulsions)
Treatment for Agitation, aggression, distress and psychosis in dementia
BENZODIAZEPINES OR ANTIPSYCHOTICS
Antipsychotic drugs should be used at the lowest effective dose and for the shortest time possible, with a regular review at least every 6 weeks.
The CHM/MHRA has reported (2009) an increased risk of stroke and a small increased risk of death when antipsychotic drugs are used in elderly patients with dementia.
Use of drugs with antimuscarinic effects should be minimised with Dementia due to cognitive impairment + increased anticholinergic burden:
antidepressants (e.g. amitriptyline, paroxetine)
antihistamines (e.g. chlorphenamine, promethazine)
antipsychotics (e.g. olanzapine, quetiapine)
urinary antispasmodics (e.g. solifenacin, tolterodine)
PARKINSONS DISEASE
Parkinson’s disease is a progressive neurodegenerative condition resulting from the death of dopaminergic cells of the substantia nigra in the brain = Decreases amount of dopamine
Motor-symptoms include - hypokinesia, bradykinesia, rigidity, rest tremor, and postural instability.
Non-motor symptoms include - dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss
In early stages of Parkinson’s -
Patients whose motor symptoms decrease their quality of life:
1ST LINE TREATMENT:
Levodopa combined with carbidopa (co-careldopa) or
Levodopa combined with benserazide (co-beneldopa)
Levodopa is converted into dopamine = restore the level of dopamine in the the brain.
Carbidopa / Benserizide helps to prevent the levodopa from being broken down into dopamine in parts of the body other than the brain.
*Can colour urine red-brown
ADVERSE EFFECT -
IMPULSE CONTROL DISORDERS
Treatment with levodopa is associated with impulse control disorders, including pathological gambling, binge eating, and hypersexuality.
Patients whose motor symptoms do not affect their quality of life:
Could be prescribed a choice of:
Levodopa ( + carbidopa or benserazide)
Non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine)
Monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).
Risk of adverse reactions from antiparkinsonian drugs include:
Psychotic symptoms
Excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists
Impulse control disorders with all dopaminergic therapy (especially with dopamine-receptor agonists)
Psychotic symptoms
Excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists
Impulse control disorders with all dopaminergic therapy (especially with dopamine-receptor agonists)
ADJUVANT THERAPY
Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered a choice of:
Non-ergotic dopamine-receptor agonists
Monoamine oxidase B inhibitors
COMT inhibitors: entacapone (reddish brown urine) or tolcapone (hepatotoxicity) as an adjunct to levodopa
Ergot-derived dopamine-receptor agonists only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist.
Daytime sleepiness and sudden onset of sleep treatment
1ST LINE - MODAFINIL to treat excessive daytime sleepiness,
Nocturnal akinesia ( term for the loss of ability to move your muscles voluntarily.)
1ST LINE - levodopa or oral dopamine-receptor agonists
2ND LINE - Rotigotine
Postural hypotension treatment
1ST LINE - MIDODRINE
2ND LINE - FLUDROCORTISONE ACETATE
Name 4 Non-ergot-derived dopamine-receptor agonists:
Pramipexole, Ropinirole, Rotigotine, Apomorphine
Risk of postural hypotension (especially on initiation)—monitor blood pressure
Cautions - Psychotic disorders; risk of visual disorders, severe cardiovascular disease
High risk of Impulse control disorders
Name 2 Ergot-derived dopamine-receptor agonist:
Bromocriptine, Cabergoline
** Fibrotic reactions - Cabergoline has been associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions. ECG is required before treatment.
Pulmonary reactions - SOB, cough
Pericardial reactions - chest pain
Name 2 Monoamine oxidase B inhibitors :
Rasagiline or selegiline hydrochloride
Commonly used for end of dose deterioration
Avoid tyramine-rich foods
Interaction with pseudoephedrine, phenylephrine = HYPERTENSIVE CRISIS
PARKINSONS + ANTIEMETICS:
WHICH TO AVOID?
WHICH TO PREFER?
AVOID - Metoclopramide + Haloperidol + Prochlorperazine
REASON : block DOPAMINE receptors and can aggravate extra-pyramidal symptoms in Parkinson
PREFER - Domperidone
REASON : does not cross BBB + acts on chemoreceptors so less likely to cause extra-pyramidal symptoms
Focal seizures with or without secondary generalization
TREATMENT
1st Line -
Carbamazepine
Lamotrigine
Alternatives - gabapentin or pregablin
Tonic-clonic Seizures
1st Line - Sodium Valproate (avoid in women)
Lamotrigine is the alternative choice
Absence Seizures
1st Line -
Ethosuximide
Sodium Valproate (Avoid in women)
Myoclonic seizures
myoclonic jerks
1st Line -
Sodium valproate
Alternative options - if Valproate unsuitable
- Topiramate
- Levetiracetam
PARKINSONS + ANTIEMETICS:
WHICH TO AVOID?
WHICH TO PREFER?
AVOID - Metoclopramide + Haloperidol + Prochlorperazine
REASON : block DOPAMINE receptors and can aggravate extra-pyramidal symptoms in Parkinson
PREFER - Domperidone
REASON : does not cross BBB + acts on chemoreceptors so less likely to cause extra-pyramidal symptoms
Domperidone max duration
7 days
Metoclopramide
Max 5 days
Mild to moderate dementia with Lewy bodies
Donepezil or rivastigmine
Antiepileptics with long half life to be given once daily at night
- lamotrigine
- phenytoin
- phenobarbital
Epileptics and driving
Pts who had first unprovoked epileptic seizure or a single isolated seizure must not drive for -
6 months
Epilepsy and driving
Pts with established epilepsy can drive a motor vehicle if -
- compliant with treatment and follow up
- seizure free for at least 1 year
- must not have a history of unprovoked seizures
Epilepsy and driving
Pts who have had a seizure whilst asleep are not permitted to drive for 1 year after each seizure unless:
- history or pattern of sleep seizure occurring only ever while asleep has been established over the course of 1 year
Or
- an established pattern of purely asleep seizures can be demonstrated over 3 years if the patient has previously had seizures whilst awake ( or awake + asleep)
Epilepsy and driving
DVLA recommend pt should not drive during :
- medication changes
- withdrawal of anti epileptic drugs and for 6 months after their last dose
If a seizure occurs due to a prescribed change or withdrawal of epilepsy treatment:
The pt will have driving license revoked for 1 yr
Pregablin and gabapentin
Rare risk of serous respiratory depression
