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PharmEducate Notes > CNS > Flashcards

CNS Flashcards

1
Q

What are the driving regulations for epileptic patients?

A

1 year without a unprovoked seizure
Or 6 months for a single isolated seizure/1st unprovoked seizure

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2
Q

What are the driving regulations for patients with sleep seizures?

A

1 year of no-awake seizures (seizures while asleep only)

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3
Q

1st line treatment for focal seizures?

A

Lamotrigine or Levetiracetam

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4
Q

1st line treatment for generalised seizures including: tonic-clonic, myoclonic, atonic/tonic seizures?

A

Sodium valproate

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5
Q

1st line treatment for generalised seizures including: tonic-clonic, myoclonic, atonic/tonic seizures in women of child bearing age or valproate not tolerated?

A

Lamotrigine or Levetiracetam

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6
Q

Treatment of absence seizures?

A

Ethosuximide

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7
Q

Treatment of absence seizures where ethosuximide isn’t suitable?

A

Sodium valproate

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8
Q

Treatment of absence seizures for a woman of child-bearing age where ethosuximide isn’t suitable?

A

Lamotrigine or Levetiracetam

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9
Q

Which antiepileptics should be prescribed by brand?

A

“CPPP”

Carbamazepine
Phenytoin
Primidone
Phenobarbital

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10
Q

How often are antiepileptics typically taken?

A

BD

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11
Q

Which antiepileptics are taken ON?

A

Phenytoin, phenobarbital, Lamotrigine

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12
Q

Which antiepileptics can be used in neuropathic pain?

A

Gabapentin and Pregabalin

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13
Q

Which antiepileptics can cause skin reactions such as Steven Johnson syndrome?

A

Lamotrigine and phenytoin

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14
Q

Which antiepileptic can cause a cleft lip when used in pregnancy?

A

Topiramate

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15
Q

Which antiepileptics can cause eye/vision disorders?

A

“TV”
Topiramate
Vigabatrin

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16
Q

Which antiepileptic can cause encephalopathy?

A

Vigabatrin

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17
Q

Which antiepileptics are present in large amounts in breast milk?

A

“ZELP”

Zosinamide
Ethosuximide
Lamotrigine
Primidone

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18
Q

Which antiepileptics can cause antiepileptic hypersensitivity syndrome?

A

“CPPP LOL”
Carbamazepine
Phenytoin
Primidone
Phenobarbital
Lamotrigine
Oxcarbamazepine
Lacosamide

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19
Q

Which antiepileptics can cause blood dyscrasias?

A

“C VET PLZ”

Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine
Zosinamide

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20
Q

Which antiepileptics have a risk of suicidal behaviour, particularly in the 1st week?

A

All of them!

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21
Q

MHRA alert for gabapentin?

A

Risk of respiratory depression, particularly when given with CNS depressants, elderly, renal impairment

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22
Q

What CD schedule is Gabapentin?

A

Schedule 3 - exempt from safe custody

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23
Q

Phenytoin therapeutic drug range?

A

10-20mg/L

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24
Q

What is the relationship between phenytoin strength and blood concentration?

A

Non-linear meaning a small change in strength results in a large increase in concentration

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25
Q

Who should be monitored more closely when prescribed phenytoin?

A

Pregnant women, < 3 month old infants, and the elderly as protein binding is decreased meaning increased levels and increased toxicity

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26
Q

Signs of phenytoin toxicity?

A

“HANDS”

Hyperglycaemia
Ataxia
Nystagmus
Diplopa (double-vision)
Slurred speech/confusion

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27
Q

Side effects of phenytoin?

A

Appearance - coarse facial features, acne, hirsutism and gingival hyperplasia

Bone disorders - give vit D if PT is immobile, reduced sun exposure or low calcium in their diet

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28
Q

Which patients are at increased risk of Steven Johnson syndrome when taking phenytoin?

A

Han-Chinese or Thai patients

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29
Q

Main phenytoin interactions?

A

Increased phenytoin concentration = NSAIDs, Warfarin and trimethoprim

Decreased seizure threshold = tramadol

Decreased levels of interacting drug = COC, theophylline and digoxin

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30
Q

Carbamazepine therapeutic drug range?

A

4-12mg/L

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31
Q

How quickly after carbamazepine is given should levels be taken?

A

1-2 weeks after starting treatment

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32
Q

Signs of carbamazepine toxicity?

A

“HAND BAG”

Hyponatraemia/hallucinations
Ataxia, Anuria (renal impairment)
Nystagmus
Drowsiness/dizziness
Blurred/double-vision
Arrhythmias
GI effects

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33
Q

Side effects of carbamazepine?

A

Bone disorders - give vit D
Hepatotoxicity
Hyponatraemia

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34
Q

Medications that decrease anticonvulsant effect of carbamazepine?

A

“SAT QT”

SSRIs
Antipsychotics
Tramadol
Quinolones
TCAs

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35
Q

What forms of contraception are acceptable in sodium valproate use?

A

IUD, implant, or COC/POP + barrier protection

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36
Q

How often is sodium valproate reviewed?

A

Annually

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37
Q

Side effects of sodium valproate?

A

Bone disorders - give vit D
Hepatotoxicity- measure LFTs and prothrombin time
Pancreatitis

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38
Q

Which antiepileptics are safe in pregnancy?

A

Lamotrigine and levetiracetam

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39
Q

What is status epilipticus?

A

Medical emergency where a seizure lasts >5mins or multiple occur in the space of 5mins. Can cause brain damage or death.

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40
Q

Treatment of status epilepticus?

A

Diazepam rectally or midazolam oromucosal solution.

Repeat after 5-10mins if necessary.

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41
Q

How soon can you repeat treatment of status epilepticus?

A

After 5-10mins

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42
Q

What is the most common cause of dementia?

A

Alzheimer’s disease

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43
Q

Example of non-cognitive symptoms of dementia?

A

Psychiatric / behavioural problems

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44
Q

MHRA alert about the use of antipsychotics in elderly patients with dementia?

A

Increased risk of stroke or death

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45
Q

What is the first line treatment of dementia?

A

“DRuGs M”
Anticholinergics - donepezil, rivastigmine or gelantamine

Memantine used in severe dementia

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46
Q

Main side effect of donepazil?

A

Neuroleptic malignant syndrome

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47
Q

Main side effect of Rivastigmine?

A

GI irritation - withhold for a short period or replace with patches

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48
Q

Main side effect with Galantamine?

A

Steven Johnson syndrome - stop at first sign of rash

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49
Q

Max dose of memantine?

A

20mg

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50
Q

Cholinergic side effects?

A

“DUMBBELS”

Diarrhoea
Urination
Muscle weakness
Bradycardia
Bronchospasms
Emesis
Lacrimation
Salivation/sweating

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51
Q

Which medications are used for the symptomatic treatment of anxiety?

A

Benzodiazepines (or buspirone) and beta blockers

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52
Q

Which beta blockers are used for physical anxiety symptoms?

A

Propranolol and Oxprenolol

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53
Q

what is Buspirone?

A

5HT1 receptor agonist used as an alternative for benzodiazepines due to low potential for abuse and dependence

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54
Q

Onset of buspirone?

A

2 weeks

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55
Q

Example of benzodiazepines?

A

Lorazepam
Diazepam
Temazepam
Oxazepam

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56
Q

Which benzodiazepine is long acting?

A

Diazepam

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57
Q

Which benzodiazepines are short acting?

A

Lorazepam and oxazepam

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58
Q

What can diazepam be used for?

A

Insomnia and dental procedures

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59
Q

Why can’t diazepam be given IV?

A

Thrombophlebitis

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60
Q

When is a short acting benzodiazepine preferred?

A

In the elderly, renal impairment or in liver impairment

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61
Q

How long can benzodiazepines be used for?

A

Short term I.E. 2-4 weeks for the relief of severe anxiety

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62
Q

What should be done to the dose of benzodiazepines in liver impairment of for the elderly?

A

Half the dose

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63
Q

Side effects of benzodiazepines?

A

Paradoxical increase in hostility

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64
Q

Symptoms of benzodiazepine overdose?

A

Ataxia, drowsiness, dysarthria (difficulty speaking), nystagmus and respiratory depression

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65
Q

Why should benzodiazepines not be withdrawn rapidly?

A

Withdrawal symptoms similar to alcohol withdrawal

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66
Q

How quickly do benzodiazepine withdrawal symptoms occur?

A

Within 1 day of stopping for SA
Within 3 weeks of stopping for LA

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67
Q

Which 3 steps should be taken when withdrawing benzodiazepines?

A
  1. Gradually convert (over a week) to equivalent diazepam dose ON
  2. Reduce diazepam dose by 1-2mg every 2-4 weeks
  3. Reduce further in smaller increments towards the end
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68
Q

At what age does ADHD typically appear?

A

3-7

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69
Q

1st line treatment for ADHD?

A

Methylphenidate

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70
Q

2nd line treatment of ADHD?

A

Lisdexamphetamine

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71
Q

What can be given in 2nd line treatment of ADHD for patients intolerant of longer effect profile?

A

Dexamphetamine

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72
Q

What CD schedule are Methylphenidate and Lisdexamphetamine?

A

Schedule 2

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73
Q

Alternative treatment for ADHD?

A

Atomoxetine or Guanfecine

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74
Q

How long are treatments trialled for in ADHD before another drug is considered?

A

Children < 5 and young adults = 6 weeks
Adults = 6 months

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75
Q

Side effects of ADHD medications?

A

Appetite loss, insomnia, weight loss, increased HR and BP, ticks and Tourette’s syndrome

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76
Q

Important side effect to monitor for in children taking ADHD medications?

A

Growth restriction - monitor height and weight and allow catch up periods for growth

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77
Q

How often should patients taking ADHD medications be monitored?

A

On starting, after dose changes and every 6 months

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78
Q

Contraindications for ADHD medications?

A

CVD, hyperthyroidism, severe hypertension, uncontrolled bipolar disorder and depression

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79
Q

Which ADHD medication is brand specific?

A

MR Methylphenidate

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80
Q

Atomoxetine side effects?

A

Suicidal ideation, hepatotoxicity, QT prolongation

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81
Q

How long can bipolar disorder episodes last?

A

Up to several weeks or months

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82
Q

What treatment options are there for acute bipolar episodes and maintenance?

A

Lithium, valproate or 2nd generation antipsychotic (quetiapine, risperidone or olanzepine) used in combination or as monotherapy

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83
Q

Lithium therapeutic drug range?

A

0.4 - 1mmol/L
(0.4 - 0.8 for prophylaxis or use in elderly)

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84
Q

How often are lithium levels measured?

A

12 hours post dose, then every 3 months for 1 year and then every 6 months (if not elderly)

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85
Q

What is the maximum period for monitoring Lithium levels in the elderly?

A

3 months

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86
Q

Signs of lithium toxicity?

A

“GREEN”

GI effects

Renal effects - Polyuria and hypernatraemia

Eyes - blurred vision

EPSEs E.g tremor

Nervous system - confusion and drowsiness

Can also cause hypothyroidism

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87
Q

What are the contraindications for lithium?

A

Low sodium diet or dehydration

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88
Q

Should patients commenced on lithium be encouraged to change diet in relation to sodium levels and hydration?

A

No. Avoid diet changes impacting sodium levels and maintain adequate fluid levels

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89
Q

Impact of hyponatraemia on lithium levels?

A

Hyponatraemia = increased Lithium concentrations predisposing to toxicity

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90
Q

What should be monitored for lithium?

A

“TCR”
Thyroid - hypothyroidism
Cardiac - QT prolongation and CVD
Renal - renal impairment

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91
Q

Side effects of lithium?

A

Benign inter-cranial hypertension, hypernatraemia, lowers seizure threshold, teratogenic and present in breast milk

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92
Q

Main interactions for lithium?

A

NSAIDs, diuretics, ACE and can cause serotonin syndrome

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93
Q

What drugs are used as antiemetics?

A

D2 receptor antagonists - domperidone and metoclopromide

1st gen antipsychotics - prochlorperazine (buccal for migraine), Levomepromazine (palliative care), droperidol and haloperidol

Antihistamines - used for vertigo and motion sickness

Antimuscarinics - Hyoscine hydrobromide (most effective for motion sickness)

5HT3 antagonists - ondansetron

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94
Q

What is 1st line treatment of nausea and vomiting in pregnancy?

A

Morning sickness is common and often self limiting so give advice on self care measures

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95
Q

What is 2nd line treatment of nausea and vomiting in pregnancy?

A

Promethazine

If this doesn’t work >24 hours switch antiemetic
If >48 hours seek specialist

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96
Q

Which patients are at higher risk of postoperative N&V?

A

Females, non-smokers, motion sickness and dependent on opioid and anaesthetic use

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97
Q

Treatment of postoperative N&V?

A

Use a combination from:
5HT3 receptor antagonists, Dexamethasone, domperidone, cyclizine or antipsychotic

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98
Q

Metoclopromide dose?

A

10mg TDS for max 5 days

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99
Q

Domperidone dose?

A

10mg TDS for max 7 days

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100
Q

Metoclopromide side effects?

A

Acute dystonic reactions (uncrontrolled movement of face/eyes)

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101
Q

Minimum age for metoclopromide?

A

18+

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102
Q

Domperidone side effects?

A

QT prolongation - report arrhythmias

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103
Q

MHRA alert for domperidone?

A

Reduced efficacy in children < 12 or < 35kg

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104
Q

Minimum age for domperidone?

A

12+

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105
Q

5HT3 side effects?

A

QT prolongation
Teratogenic in 1st trimester (ondansetron)
Serotonin syndrome

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106
Q

When are 5HT3 receptors used for N&V?

A

Postoperative and chemotherapy induced

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107
Q

1st line treatment for schizophrenia?

A

Antipsychotic

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108
Q

When is a patient considered to have resistant schizophrenia?

A

When they have tried 2 or more antipsychotics including a second generation one

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109
Q

What is given for resistant schizophrenia?

A

Clozapine +/- antipsychotic

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110
Q

What route are antipsychotics given in acute episodes?

A

IM at a lower dose and reviewed daily

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111
Q

What dose of antipsychotic is given to the elderly compared to a normal dose?

A

Half normal dose and only used in severe conditions and reviewed regularly

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112
Q

What should be done in patients with learning disabilities if they have no psychotic symptoms?

A

Decrease the dose or discontinue and review. Requires annual documentation for treatment reasoning.

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113
Q

When is a 1st generation antipsychotic preferred?

A

If a patient has or is at high risk of diabetes, overweight or requires fewer metabolic side effects

114
Q

When are 2nd generation antipsychotics preferred?

A

When patients at risk of EPSEs as 2nd gen antipsychotics pose lower risk or presents with negative symptoms

115
Q

How many groups of 1st gen phenothiazine antipsychotics are there?

A

3

116
Q

Which group of 1st gen antipsychotics are the most sedative?

A

Group 1 “promazine”

117
Q

Which group of 1st gen antipsychotics pose the least risk of EPSEs?

A

Group 2 “cyazine”

118
Q

Which group of 1st gen antipsychotics pose the highest risk of EPSEs?

A

Group 3 “phenazine / perazine”

119
Q

Non-phenothiazine 1st generation antipsychotics?

A

Butyrophenones - haloperidol
Thioxathenes - Flupentixol
Pimozide

120
Q

Examples of 2nd generation antipsychotics?

A

Risperidone
Olanzapine
Quetiapine
Aripiprazole
Clozapine
Amisulpride

121
Q

Which antipsychotics are associated with the most hyperprolactinaemia?

A

All first gens and Risperidone and Amisulpride

122
Q

Which 2nd gen antipsychotics are associated with the most weight gain and diabetes?

A

“C ROQ”

Clozapine
Respiridone
Olanzapine
Quetiapine

123
Q

Which 2nd gen antipsychotic doesn’t cause hyperprolactinaemia?

A

Aripiprazole

124
Q

What are the impacts of hyperprolactinaemia?

A

Breast enlargement
Galactorrhea
Menstrual disturbances
Sexual dysfunction
Reduced bone density

125
Q

How often do patients taking an antipsychotic require CV risk assessment due to CV side effects of the drugs?

A

Yearly

126
Q

Side effects of all AP drugs?

A

Neuroleptic malignant syndrome - stop on signs of muscle rigidity, fluctuating consciousness, hyperthermia

Seizure
Photosensitivity
QT prolongation and arrhythmias
Hypotension

127
Q

Which 2nd gen AP is the most effective?

A

Clozapine

128
Q

Which antipsychotic doesn’t effect QT?

A

Aripiprazole

129
Q

What are examples of EPSEs?

A

Parkinsonism (E.g. tremors)
Dystonia (abnormal face and body movements)
Dyskinesia (involuntary muscle movements)
Tardive dyskinesia (rhythmic involuntary movements of tongue, face or jaw)

STOP AT FIRST SIGN

130
Q

When is clozapine an option?

A

Resistant schizophrenia with trial of 2+ antipsychotics for 6-8weeks failing

131
Q

How long is clozapine trialed for to assess effectiveness?

A

8-10 weeks

132
Q

How many clozapine tablets can be missed before requiring re-titration?

A

2 doses = re-initiated

133
Q

Side effects of clozapine?

A

“MAG”

Myocarditis and cardiomyopathy - STOP. Persistent tachycardia in first 2months prompts observation.

Agranulocytosis and neutropenia - report signs of infection. WCC measured every week for 18 weeks, then every 2 weeks for a year, then monthly.

Gastrointestinal obstruction - report constipation, faecal impaction before next dose.

134
Q

Can Hyoscine butylbromide be used for hyper-salivation in clozapine patients?

A

No due to constipating effect

135
Q

Symptoms of Parkinson’s disease?

A

Tremors
Hypo/bradykinesia
Instability

136
Q

What determines treatment pathway for Parkinson’s disease?

A

Impact on quality of life

137
Q

1st line treatment of PD if QoL is decreased?

A

Levodopa

138
Q

1st line treatment of PD if QoL has not decreased?

A

non-ergot D2 receptor agonist
Or Levodopa / MAOIb

139
Q

Adjunct options to 1st line treatment of PD if QoL is decreased and has motor complications?

A

+ non-ergot derived D2 receptor agonist / MAOIb / COMT inhibitor

140
Q

Why should ergot-derived D2 receptor agonists be avoided in PD?

A

Due to side effects such as fibrotic reactions, pulmonary toxicity, cardiac impairment and abdominal pain

141
Q

What is the impact of stoping dopaminerigc drugs rapidly?

A

Neuroleptic malignant syndrome
Acute akinesia (loss of voluntary movement)

142
Q

Treatment of nausea and vomiting in PD?

A

Domperidone

143
Q

Main side effect of dopaminerigc drugs?

A

Addiction-like symptoms - Report

144
Q

Examples of MAOiBs?

A

Rasagiline
Selegiline (metabolises to amphetamine - caution in driving)

145
Q

Examples of COMTis?

A

Entacapone (colours urine red-brown)
Tolcapone (hepatotoxic)
Opicapone

146
Q

What colour does entacapone colour urine?

A

Red-brown

147
Q

Examples of ergot-derived D2 receptor agonists?

A

Bromocriptine
Cabergoline
Pergolide

148
Q

Examples of non ergot-derived D2 receptor agonists?

A

Pramipexole
Ropinerole (effected by smoking)
Rotigotine

149
Q

Other d2 receptor agonists?

A

Apopmorphine (used in advanced disease for “off periods”)
Amantadine (weak)

150
Q

Apopmorphine side effect?

A

QT prolongation

151
Q

D2 receptor agonist side effects?

A

Impulse and sudden sleep onset
Psychotic reactions E.g. hallucinations
Hypotensive reactions

152
Q

Levodopa side effects?

A

Impulse control disorders
Sudden sleep onset
Motor complications E.g. dyskinesia, on-off periods (MR preparations can help)

153
Q

MAOiB side effects?

A

Hypertensive crisis and serotonin syndrome

154
Q

COMT side effects?

A

Entacapone = red-brown urine
Tolcapone = hepatotoxicity

Increased cardiovascular effects

155
Q

1st line for moderate to severe depression?

A

SSRI +/- CBT

156
Q

Alternatives to 1st line treatment of moderate - severe depression?

A

SNRI or another antidepressant used previously by the patient

157
Q

Treatment for severe depression requiring rapid response?

A

Electroconvulsive therapy

158
Q

How long should antidepressants be trialled before deemed ineffective?

A

4 weeks

159
Q

How long should antidepressants be taken for post remission?

A

6 months
12 months if elderly

160
Q

How long should antidepressants be taken for in generalised anxiety disorder?

A

12 months

161
Q

How long should antidepressants be taken for in recurrent depression?

A

2 years

162
Q

How long do antidepressants take to work?

A

2 weeks
Review every 1-2 weeks at the start of treatment

163
Q

Examples of irreversible MAOis?

A

Phenelazine
Isocarboxazid
Tranyleypromine (most likely to cause hypertensive crisis)

164
Q

Which MAOI is reversible as it is short-acting and therefore has no washout period?

A

Moclobemine

165
Q

Examples of SSRIs?

A

Citalopram / Escitalopram (QT prolongation)
Fluoxetine (licensed for use in kids)
Sertraline (licensed for use in MI and stable angina)
Paroxetine (greatest risk of withdrawal)

166
Q

Which SSRIs have the highest risk of QT prolongation?

A

Citalopram and Escitalopram

167
Q

Which SSRI is licensed for use in kids?

A

Fluoxetine

168
Q

Which SSRI is safest in MI and stable angina?

A

Sertraline

169
Q

Which SSRI has the greatest risk of withdrawal?

A

Paroxetine

170
Q

Examples of TCAs?

A

Amitryptylline
Nortriptylline
Clomiprimine
Imipramine
Dosulepin
Lofepramine
Mirtazapine

171
Q

Which TCAs can be used for neuropathic pain?

A

Amitryptylline
Nortryptlline

172
Q

Which TCA has the the most antimuscarinic effect?

A

Imipramine

173
Q

Which TCA is safest in hepatic impairment?

A

Lofepramine

174
Q

Which TCA can cause blood dyscrasia?

A

Mirtazepine

175
Q

General side effects of antidepressants?

A

Drowsiness
Hyponatraemia (most common in SSRIs) leading to confusion and convulsions

176
Q

Symptoms of serotonin syndrome? (3)

A
  1. Neuromuscular hyperactivity - tremor, myoclonus, muscle rigidity
  2. Altered mental state - confusion, agitation and mania
  3. Autonomic dysfunction - tachycardia, labile BP, urination, hyperthermia, diarrhoea, shivering and sweating
177
Q

Drugs that can cause serotonin syndrome?

A

“OL TMSSS”

Ondansetron
Lithium
Tramadol/TCAs
MAOIs
Sumatriptan
SJW
SSRI/SNRI

178
Q

Wash out period for MAOIs?

A

2 weeks
Except moclobemide

179
Q

Which MAOI doesn’t have a washout period?

A

Moclobemide

180
Q

SSRI washout period?

A

1 week
2 weeks for sertraline
5 weeks for fluoxetine

181
Q

Which SSRI has a 2 week washout period?

A

Sertraline

182
Q

Which SSRI has a 5 week washout period?

A

Fluoxetine

183
Q

Washout period for TCAs?

A

1-2 weeks
3 weeks for comipramine and imipramine

184
Q

Which TCAs have a 3 week washout period?

A

Clomipramine and Imipramine

185
Q

Side effects of SSRIs?

A

“SIGHS QA”

Serotonin syndrome
Increased bleeding risk
GI upset
Hyponatraemia
Skin rash (hypersensitivity)

QT prolongation
Appetite change and weight gain/loss

186
Q

TCA side effects?

A

“TCAS”

Toxicity > SSRIs in overdose
Cardiac effects E.g. arrhythmias and hypotension
Antimuscarinic effects
Seizures

187
Q

Which TCA also causes QT prolongation and arrhythmias?

A

Clomipramine

188
Q

When should TCAs be given?

A

At night due to sedative effect

189
Q

MAOI side effects?

A

Hypertensive crisis - contraindicated in CVD and stroke

Hepatotoxicity - most with phenalazine and isocarboxazide

Postural hypotension - discontinue if palpitations or frequent headaches

190
Q

Which 2 antidepressants can never be given together?

A

MAOI and TCAs = severely toxic reactions

191
Q

Patient counselling for MAOIs?

A

Avoid tyramine rich foods for up to 2 weeks after treatment due to risk of hypertensive crisis.
Eat fresh foods and avoid alcohol.

192
Q

3 types of pain?

A

Nociceptive - caused by tissue damage
Neuropathic - caused by nerve damage
Nociplastic - caused by sensitisation to changes in the pain pathway

193
Q

What is step 1 in the pain ladder (mild)?

A

Non-opioid simple analgesic

194
Q

What is step 2 in the pain ladder (mild-moderate)?

A

Weak opioid E.g. codeine or hydrocodeine
Or moderate opioid E.g. tramadol

+/- non-opioid

195
Q

What is step 3 in the pain ladder (moderate-severe)?

A

Strong opioid +/- non-opioid

196
Q

At what step in the pain ladder can you add an adjuvant?

A

Any

197
Q

Which adjuvant can be added for neuropathic pain?

A

TCA or anti-epileptic

198
Q

Which adjuvant can be added for nerve compression pain?

A

Dexamethasone

199
Q

Which adjuvant can be added for bone metastasis in pain?

A

Bisphosphonates

200
Q

Which adjuvant can be added for muscle spasms in pain?

A

Benzodiazepines

201
Q

What schedule are weak opioids?

A

CD5
(Codeine IM injection = CD 2)

202
Q

When is codeine CD 2?

A

When given IM

203
Q

What schedule is tramadol?

A

CD 3

204
Q

What schedule are strong opioids?

A

CD 2
Buorenorphine = CD 3
Morphine oral solution <14mg/mL = CD 5

205
Q

What schedule is buprenorphine?

A

CD 3

206
Q

When is morphine considered CD 5?

A

When given as an oral solution <14mg/L

207
Q

Max dose of paracetamol for adults?

A

0.5-1g QDS max 4g in one day

208
Q

Impact of paracetamol overdose?

A

Liver damage

209
Q

When are patients at increased risk of paracetamol toxicity?

A

<50kg

210
Q

What can be given for paracetamol overdose?

A

Acetylcysteine

211
Q

Aspirin max adult dose?

A

300-900mg every 4-6 hours
Max 4g in one day

212
Q

Side effects of aspirin?

A

GI irritation
Tinnitus at high doses
Risk of bleeding - caution with warfarin

213
Q

What is the age restriction for aspirin and why?

A

Contraindicated for <16 years old due to risk of Reye’s syndrome

214
Q

Exemption from age restriction for aspirin?

A

When given for kawasakis disease in under 16s

215
Q

When is opioid toxicity most common?

A

When given for over 3 months

216
Q

Treatment of opioid induced constipation?

A

Osmotic + stimulant laxative

217
Q

Treatment of opioid induced N&V?

A

Metoclopromide

218
Q

What route can codeine and dihydrocodeine never be given?

A

IV due to severe anaphylactic reactions

219
Q

What age is codeine and dihydrocodeine licensed for?

A

12+

220
Q

Max dose for children over 12 taking codeine or dihydrocodeine?

A

240mg every 6H for max 3 days

221
Q

Additional side effects when giving tramadol compared to other opioids and why?

A

Also effects NA and 5HT3 pathways meaning it can also cause psychiatric reactions, reduce seizure threshold and cause serotonin syndrome

222
Q

Which strong opioid is most suitable for renally impaired patients?

A

Oxycodone

223
Q

Usual morphine dose?

A

Every 4 hours or every 12-24 hours for MR

224
Q

Parenteral morphine dose compared to oral dose?

A

Half

225
Q

Benefits of diamorphine over morphine?

A

Reduced N&V and hypotension

226
Q

Symptoms of migraine?

A

Throbbing pain on one side
N&V
Sensitivity to light or sounds

227
Q

Warning signs of migraines?

A

Visual disturbances
Sensory numbness/tingling which radiates from one hand up the arm and to the face, lips and tongue
Dizziness
Dysphagia (difficulty speaking)

228
Q

How many headaches/migraines a month is considered episodic?

A

<15days a month

229
Q

How many migraines/headaches is considered chronic?

A

15+ days a month

230
Q

How many times a week can acute migraine attacks be treated?

A

Max 2 days a week to avoid aggregation of headaches

231
Q

1st line treatment of migraines?

A

Aspirin/ibuprofen OR Sumatriptan
(Take when headaches start, not when aura occurs)

232
Q

2nd line treatment of migraines?

A

Sumatriptan + Naproxen

233
Q

Treatment of nausea and vomiting in migraines?

A

Metoclopramide or domperidone

234
Q

What can be given as migraine prophylaxis?

A

Beta blocker = propranolol
Alternatives = atenolol, bisoprolol, metoprolol, nadolol, timolol

235
Q

What can be given as migraine prophylaxis if the patient cannot tolerate a beta blocker?

A

Topiramate

236
Q

How should 5HT1 receptor agonists such as sumatriptan be taken in migraines?

A

1 tablet ASAP after onset
Another tablet can be taken after 2 hours if not for the same attack (4 hours for naratriptan)

237
Q

5HT1 receptor agonist side effects?

A

Coronary vasoconstriction - report tightness or heat in chest or throat

Serotonin syndrome

238
Q

Contraindications for 5HT1 receptor agonists?

A

MI
Cardiovascular issues E.g. stroke, angina or uncontrolled hypertension

239
Q

What is transient insomnia?

A

When insomnia is caused by environmental factors

240
Q

Treatment of transient insomnia?

A

1-2 doses of SA hypnotic

241
Q

What is short term insomnia?

A

Insomnia caused by emotional or serious illness

242
Q

Treatment of ST insomnia?

A

Give intermittent SA hypnotic for less than 3 weeks

243
Q

What is chronic insomnia?

A

Insomnia caused by psychiatric or physical illness

244
Q

Treatment of chronic insomnia?

A

Treat underlying cause

245
Q

Which drugs are used as hypnotics?

A

Z-drugs (CD4 part 1)
Benzodiazepines (CD4 part 1)

246
Q

Are z drugs short or long acting?

A

Short acting

247
Q

Main side effects of z drugs?

A

Respiratory depression
Dependence and tolerance
CNS depression

248
Q

Which benzodiazepines are short acting?

A

Temazepam and Lorazepam

249
Q

Examples of long acting benzodiazepines?

A

Diazepam, Flurazepam, nirtazepam

250
Q

What is the main benefits of short acting hypnotics over long acting ones?

A

Little hangover effect the next day

251
Q

What is the main benefits of long acting hypnotics over long acting ones?

A

Anxiolytic effect during the day

252
Q

What CD schedule is Temazepam?

A

CD 3

253
Q

What is narcolepsy?

A

A LT condition causing patients to suddenly fall asleep at inappropriate times

254
Q

Treatment of narcolepsy?

A

CNS stimulants E.g. modafinil and dexamethasone

255
Q

Can modafinil be used in pregnancy?

A

No. Use contraception for up to 2months after treatment

256
Q

Max treatment use of Z drugs?

A

4 weeks max
2 weeks for zaleplon

257
Q

What is the most effective approach to quit smoking?

A

Abrupt quitting + cessation aids + behavioural support

258
Q

What cessation aids are available to aid smoking cessation?

A

Varenicline
Or LA + SA NRT

259
Q

What other medications are used in smoking cessation?

A

Bupropion (SNRI)

260
Q

Bupropion side effects and counselling?

A

Can cause serotonin syndrome or psychological effects - report

261
Q

What can be given for moderate-severe alcohol withdrawal symptoms?

A

Chlordiazepoxide or diazepam
Can be given as a fixed dose or symptom triggered regimen

262
Q

What is used for alcohol withdrawal seizures?

A

Lorazepam

263
Q

What can be given for delirium tremens in alcohol withdrawal?

A

Oral lorazepam
If persistent or declines, can give parenterally or give haloperidol

264
Q

Treatment of mild alcohol dependence?

A

Psychological therapy E.g. CBT

265
Q

Treatment of moderate-severe alcohol dependence?

A

Acamprosate or Naltrexone
+ psychological therapy

Alternative = Disulfiram

266
Q

When should treatment of moderate-severe alcohol dependence be started?

A

On withdrawal of alcohol

267
Q

Caution with disulfiram?

A

Unpleasant systemic reactions E.g. headaches or facial flushing, with any amount of alcohol.

Large amounts of alcohol can cause arrhythmias or hypertension

268
Q

When is nalmefene an option in alcohol dependence?

A

Used to help reduce drinking. Used when there is an increased risk of drinking but no current withdrawal symptoms

269
Q

Treatment of wernicke’s encephalopathy?

A

Thiamine (vit B1) parenterally then orally

270
Q

Prevention of wernicke’s encephalopathy?

A

Oral thiamine (vit B1)

271
Q

What two options are there for opioid dependence?

A

Methadone and buprenorphine

272
Q

How often are methadone and buprenorphine taken?

A

OD

273
Q

Main methadone side effect?

A

QT prolongation

274
Q

When is methadone preferred?

A

It has a long half life meaning it is more sedative which is good for anxiety, patients who abuse sedatives, or long history of opioid abuse

275
Q

Main side effect of buprenorphine?

A

Precipitates withdrawal therefore should only be started once withdrawal symptoms begin or 6-12 hours after drug use

276
Q

Benefit of buprenorphine over methadone?

A

Less sedative therefore good for people with jobs and safer with concomitant sedative drugs.
Can also be given at a higher dose on alternative days

277
Q

What should be done if 3 days of methadone/buprenorphine have been missed?

A

Risk of overdose therefore requires retitration

278
Q

What should be done if 5 days of methadone/buprenorphine have been missed?

A

Check for drug misuse before retitrating as buprenorphine can precipitate withdrawal symptoms

279
Q

Is clozapine effected by smoking?

A

Yes - monitor levels if a patient quits or switches to e-cigarettes

280
Q

Interaction between carbamazepine and Clarithromycin/erythromycin?

A

Increases carbamazepine levels

281
Q

Symptoms of Steven-Johnson’s syndrome?

A

Flu like symptoms followed by a painful red or purple blistering rash

PharmEducate Notes (8 decks)

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