CNS Flashcards
1
Q
1st line tx of focal seizures
A
lamotrigine/levetiracetam
2
Q
2nd line tx of focal seizures
A
carbamazepine, oxcarbazepine, zonisamide
3
Q
different types of generalised seizures
A
-tonic-clonic
-absence
-absence + other
-myoclonic
-atonic
-tonic
-for child-bearing age = 2nd line tx
4
Q
tx of tonic-clonic seziures
A
1)sodium valproate
2)lamotrigine, levetiracetam
5
Q
tx of absense seizures
A
1)ethosuximide
2)sodium valporate
6
Q
tx of absence + other type of seizures
A
1)sodium valproate
2) lamotrigine/ levetiracetam
7
Q
myoclinic seziures tx
A
1)sodium valproate
2) levetriacetam
8
Q
atonic seziures tx
A
1)sodium valproate
2)lamotrigine
9
Q
tonic seizures tx
A
1)sodium valproate
2)lamotrigine
10
Q
what is status epilepticus
A
-seizures that last longer than 5 mins
-need to provide resuscitation and immediate emergency tx
1)pt = individualised emergency manage plan
2)pt = x “”
11
Q
status epilepticus tx
A
-Standard tx
1) longer than 5 mins
->IV lorazepam (resuscitation if available)
->buccal midazolam/rectal diazepam (community)
–>give second dose if seizure x stop within 5-10mins of 1st dose
2)if seizure x respond after 2x benzodiazepine doses
-> levetiracetam, phenytoin, sodium valproate
3) if seizure fails to respond try another 2nd line if still x respond
->phenobarbital/general anaesthesia
12
Q
category 1 of anti-epileptic drugs
A
-specific brands only
-carbamazepine, phenobarbital, phenytoin, primidone
13
Q
category 2 of anti-epileptic drugs
A
- maintain specific brands based on clinical judgement + pt factors
-clobazam, clonazepam, lamotrigine, oxcarbazepine, perampanes, rufinamide, topiramate, valproate, zonisamide
14
Q
category 3 of anti-epileptic drugs
A
-unnecessary to ensure - specific brands
- brivaracetam, ethosuximide, gabapentin, laxosamide, levetiracrtam, pregabalin, tigabine, vigabatrin
15
Q
anti-epileptic drug interactions
(carbamazepine, phenytoin, sodium valproate)
A
-hepatotoxicity - amiodarone, itraconazole, macrolides, alcohol
-CYP enzymes - inducers (phenytoin, phenobarbital + carbamazepine) inhibitors (sodium valproate)
-drugs lower seizure threshold - tramadol, theophylline, quinolones, —>carbamazepine = hyponatraemic drugs (SSRI + diuretics)
->phenytoin = anti-folate(methotrex + trimethoprim)
16
Q
carbamazepine, phenytoin, sodium valproate s/e
A
-carbamazepine, phenytoin, sodium valproate
->suicide, depression, hepatotoxicity, hypersensitivity, blood dyscrasia, vit D deficiency
-carbamazepine; hyponatraemia, odema
-phenytoin; coarsening appearance, facial hair
-sodium valproate; pancreatitis, teratogenic
17
Q
anti-epileptic drug s/e
A
-hypersensitivity - carbamazepine, phenobarbital, phenytoin, primidone, lamotrigine
-skin rash - lamotrigine (steven-johnson syndrome)
-blood dyscrasia - carbamazepine, valproate, ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide
-eye disorder - vigabatrin (reduce visual field) topiramate (secondary glaucoma)
-encephalopathy - vigabatrin
-respiratory depression - gabapentin + pregabalin
18
Q
carbamazepine range + signs of toxicity
A
-therapeutic range- 4-12mg/l
-Hyponatraemia
-ataxia (poor muscle control)
-nystagmus (involuntary movement of eyes)
-drowsiness
-blurred vision
-arrythmias
-GI disturbances
19
Q
phenytoin range + signs of toxicity
A
-therapeutic range - 10-20mg/l
-slurred speech
-nystagmus (involuntary mov of eyes)
-ataxia (poor muscle control)
-confusion
-hyperglycaemia
-double vision
20
Q
epilepsy + driving
A
-stop driving + inform DVLA (fit)
-1st unprovoked/single isolated = 6MT
-established epilepsy = 1yr (or pattern of seizures established for 1yr with no impact on consciousness)
-medication change/withdrawal - x drive 6MT after last dose, seizure = occur license removed for 1yr, reinstated for after 6MT if tx resumed + no seizure occur
21
Q
epilepsy + pregnancy
A
-risk of harm to mother + fetus from convulsive seizures outweighs risk of continued therapy
-folic acid given to reduce risk of neural tube defects in 1st trimester
-vit K inj adminstered - birth reduces neonatal haemorrhage
-most risk - sodium val -PPI
- topiramate - celft palate
22
Q
what is bipolar disorder
A
extreme fluctuation between maniac phases (overactive + excitability) + depressive phases (reclusive + lethargic)
23
Q
tx acute of bipolar disorder
A
-benzodiazepines
-antipyschotics (quetiapine, olanzapine/risperdone)
-> add lithium or sodium valproate
24
Q
tx prophylaxis of bipolar disorder
A
-carbamazepine, sodium valproate or lithium
25
lithium range
-therapeutic range - 0.4-1mmol/l (acute episodes - 0.8-1)
-measure levels 12hr after each dose - weekly till stable then 3MT X 1YR * 6MT
26
lithium toxicity
-CUT-DVB
Renal impairment - incontinence
-extrapyramidase s/e - tremor
-visual disturbance - blurred vision
-nervous system disorder - confusion + restlessness
-diarrhoea + vomiting
27
lithium s/e
-QT2-BNR
thyroid disorder
-nephrotoxicity
-rhabdomyolysis
-QT prolongation
-benign intercranial hypertension
-1st trimester = teratogenic
28
lithium interactions
-hyponatraemia = high risk of toxicity - diuretics
-salt imbalance
-serotonin syndrome
-extrapyramidal s/e
-QT prolongation
-renally cleared drugs (high risk of toxicity
-dec seizure threshold
-hypokalmaeia
29
dementia?
alleviated by high amount of acetylcholine
30
tx of dementia mild to moderate
-acetylcholinesterase inhibitors
-donepezil = neuroleptic malignant syndrome
-rivastigmine - GI s/e - less in transdermal formulations
-galantamine -steven-johnsons syndrome
31
tx of dementia moderate to severe
- memantine
-aggravation tx with benzodiazepines or antipsychotics
32
s/e of dementia tx
-high acetylcholine = parasympathetic s/e
-stop tx + tx dehydration before reinitiating/amending dose
-diarrhoea
-urinary incontience
-muscle weakness
-bradycardia
-bronchospasm
-emetis
-lacrimation
-salivation
33
parkinsons?
alleviated levels of dopamine
34
pt = parkinsons whose motor symptoms reduce QoL tx
levodopa + carbidopa/berserazide
35
pt = parkinsons whose motor symptoms x affect QoL TX
- levodopa
-non-ergot derived dopamine receptor
-monoamine-oxidase B inhibitors
36
what is added to levodopa in order to prevent breakdown of levodopa before it crosses into the brain
-carbidopa/benserazide is added
-impulsive disorders; pathological gambling, binge eating, hypersexuality
-sudden onset of sleep (tx modafinil) red urine
37
non-ergot derived dopamine-receptor -
pramipexole, ropinirole + rotigotine
-impulse disorders (higher than levodopa)
-sudden onset of sleep
-hypotension
38
-rasagiline or selegiline interactions
monoamine-oxidase B inhibitors
-causes hypertensivie crisis if given with phenyleprine
-interacts with tyramine rich foods
->mature cheese, salami, marmite, yeast, tofu
39
when is non-ergot dopamine receptor agonists, monoamine oxidase B inhibitors or COMT inhibitors added to levodopa
it is added to levodopa in pt who develops dyskinesia or motor fluctuations despite optimal levodopa therapy
40
entacapone and tolcapone
-COMT inhibitors
-entacapone - red-brown urine
- tolcapone - hepatotoxic
- inc sympathetic s/e in CVD events
41
when is ergot dervied dopamine receptor agonist added to levodopa
- if symptoms x adequately controlled with non-ergot ""
42
ergot dervied receptor agonists -
bromocriptine, cabergoline
- pulmonary reactions; report SoB, chest pain, cough
-pericardial reactions; chest pain
43
withdrawal of medications
-if person = off-periods due to deterioation use MR preparations
-tx natural akinesia with levodopa or oral dopamine receptor agonists as 1st line + rotigotine - 2nd line
-tx hypertension = midodrine
44
psychosis + schizophrenia +ve symptoms
delusions, hallucinations, disorganisations
45
psychosis + schizophrenia -ve symptoms
social withdrawal, neglect, poor hygiene
46
antipsychotics 1st gen
phenothiazines
thioxanthenes
butyprohenones
47
antipsychotics 2nd gen
olanzapine
clozapine
risperidone
quetiapine
aripiprazole
ziprasidone
paliperidone
asenapine
lurasidone
iloperidone
48
antipsychotics how many groups of phenothiazines
group 1
group 2
group 3
49
1st gen phenzothiazines group 1
-chlorpromazine, levomepromazine, promazine
-most sedation, moderate antimuscarinic + EPSEs
50
1st gen phenzothiazines group 2
-pericyazine
-moderate sedation least EPSEs
51
1st gen phenzothiazines group 3
-fluphenazine, prochlorperazine, trifluoperazine
-moderate sedation high EPSEs
52
benperidol + haloperidol
-1st gen butyrophenones
-moderate sedation high EPSEs
53
flupentixol, zuclopentinixol
- 1st gen thioxanthies
- moderate sedation, antimuscarinic effects + EPSEs
54
1st gen others
-pimozide + sulpride
-reduced sedation, antimuscarinic effects +EPSEs
55
2nd gen antipsychotics
-amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone
56
antipsychotics s/e
-extrapyramidal - group 3 phenothiazines + butyropheriones
- hyperprolactinaemia = less in aripiprazole
- sexual dysfunction = all
- cardiovascular - QT prolongation pimozide + haloperidol
57
common antipyschotic s/e
-hypertension - clozapine + quetiapine
-hyperglycaemia - clozapine, risperidone, olanzapine, quetiapine
-weight gain; olanzapine + clozapine
-neuroleptic malignant syndrome stop tx and tx with bromocriptine (should resolve 5-7DY)
58
antipyschotics monitoring
-weight; weekly for 6W*12WK*1YR*yearly
-fasting blood glucose, hb2ac, blood lipid conc - @12WK*1YR*yearly
-ECG - before initiation
-blood pressure: @12WK*1YR*yearly
-FBC, U+Es, LFT= @ start then yearly
59
clozapine
-used in resistant schizo
-only when 2+ antipyschotics including one 2nd has been used for 6-8WK each
-IF MISSED MORE THAN 2 DOSES = SPECIALIST REINITIATION
-monitor levocyte + differentia blood counts
->weekly 18wk
->every 2 weeks for 1 yr
->monthly
60
clozapine s/e
-myocarditis + cardiomyopathy - report + stop tachycardia
-agranulocytes + neutropenia - monitor leucocyte + different blood counts
-GI disturbances
61
anxiety tx acute
benzodiazepines
62
chronic anxiety tc
SSRI- sertaline, citalopram, escitalopram, fluoxetine, propanolol - alleviates physical symptoms only
63
benzodiazepines
-can induce hepatic coma especially long-acting benzodiazepines tx with lowest dose for shortest time
64
benzodiazepines short-acting
-lorazepam + oxazepam
-preferred in elderly + hepatic impairment
- greater risk of withdrawal symptoms (2-4wk)
65
benzodiazepines long-acting
diazepam, alprazolam, chlordiazepoxide , hydrochloride, clobazam
66
benzodiazepines paradioxial effects
-agression, hostility, talkative, anxious, excited
67
benzodiazepines sedation
increased with sue of alcohol, CNS depressants or CYP enzyme inhibitors avoid concomitant use
68
benzodiazepines driving
-avoid if drowsy
-legal driving limit = clonazepam, axaepam, lorazepam, diazepam, flunitrazepam + temazepam
69
benzodiazepines overdose tx
flumazenil
70
benzodiazepines withdrawal
-dependence; anxiety, sweating, weight loss, tremors, loss of appetite
1)convert all medciation to ON dose of diazepam
2) reduce by 1-2mg (1/10th of larger doses) every 2-4wk - only withdraw further if overcome withdrawal symp
3) reduce further 0.5mg near end
71
depression
less serotonin, dopamine, norephedrine, atosynaptic cleft
72
mild depression tx
-CBT
73
moderate to severe depression tx
-antidepressants
-pt may feel worse in 1st 1-2WKs
-should be taken for 4WK (6wk elderly) before seen as ineffective
-take for 6MT after remission, 1yr elderly, 2yr - recurrent
74
depression tx
-1st line = SSRI
- x work:
-> inc dose
-> change SSRI
-> mirtazepine
-> MAOI-I (specialist)
-> TCA or venlafaxine (severe)
- x work after changes then add another class - lithium or antipsychotics
-use electroconvulsive therapy = severe refractory depression
75
SSRI s/e
-GI (D+V)
- appetite / weight gain
- sexual dysfunction
- risk of bleed
-insomnia (take in morning)
QT prolongation (escitalopram + citalopram)
76
SSRI interactions
-CYP inhibitors - avoid grapefruit inc plasma conc
-CYP inducers lower effectivness
-drugs - QT prolongation = amiodarone, sotalol, quinolones
-drugs inc risk of bleed
-hyponatraemia = carbamazepine _ diuretics
-serotonin syndrome
77
serotonin syndrome
-cognitive effects; headaches, agitation, hypomania, coma, confusion,
-autonomic; sweating, hyperthermia, nausea, diarrhoea
-neuromuscular exictation; myclonus, tremor, teeth grinding
-caused by
->SSRI, TCA, MAO-I
->triptans
->tramadol
->lithium
78
TCA
-sedating - better for agitated + anxious pt
-> amitriptyline, clomipramine, dosulepim, trazadone
-less sedating = better for withdrawn ) apathetic pt
->imipramine, lofepramine, nortriptyline
-amitriptylline + dosulepin = dangerous overdose
79
TCA s/e
-cardiac events
-anti-muscarnic
-seizures
-hypotension
-hallucinations
80
TCA interactions
-cyp inhibitors (avoid grapefruit)
- cyp inducers ( reduce effectiveness)
-drugs = QT prolongation
-anti-muscarinic drugs
-anti-hypertensive drugs
-serotonin syndrome
81
MAOI-I
-specialist use
-causes hepatotoxicity phenazine + isocarboxazid
-hypertensive crisis X pseudoephedrine
- avoid tryamine rich foods
-tranylcypromine + clomipramine = fatal
82
MAOI washout period
-antidepressant = x start for 2wk after tx with MOAI (3wk for clomipramine or imipramine)
- x start MOAI until
-> 2wk after previous MOAI has been stopped (0WK for meclobemide)
->1-2wk after TCA or related has been stopped
-1wk after SSRI or related antidepressants x (5WK fluoxetine)
83
transient insomnia
-external factors - noise, shift work, jet lag
-rapidly eliminated hypnotic = chosen _ only 1/2 doses given
84
short term insomnia
-emotional problem or serious medical illness
-hypnotic useful x given for more than 3 wk (1wk ideal)
85
chronic insomnia
-normally = anxiety, depression, alcohol/drug abuse
-underlying psychiatric compliant = tx
86
benzodiapines insomnia long acting
nitrazepam, diazepam, flurazepam
-higher hangover effect following day
-used for sleep disturbances
87
benzodiapines insomnia long acting
-loprazolam, lermetazepam, temazepam
-little or no hangover effect
-sleep onset
-high chance of withdrawal symptoms
88
Z-hypnotics
-zolpidem + zopiclone
-high GABA - CNS depression
-dependency occurs within 3-14DY of use
-should be taken intermittently
-should be used for 4wk max
-benzo + z-drugs avoid in elderly due to falls + injury
-parodoxidal S/E
-drowsiness
dependence
89
children 5+ ADHD
1) methylphenidate = 1st line
2) if 6wk trial at max dose x work then switch to lisdexamfetamine (dexamfetamine if x tolerate longer duration)
-if intolerant to both methyl + lisde - 3) atomxetine or guanfacine
90
TX of adult ADHD
1)methylphendiate or lisdexamfetamine (dexamefatamine x tolerate)
2) atomextine ( causes QT prolongation, hepatotoxicity, suicidal ideation)
-MR prep = preferred - brand specific
-> pharmacokinetic profile, convivence increase adherence
91
methylphendiate
-CNS stimulant
-inc BP, tachycardia + arrythmias
-behaviour/mood change, drowsiness + sleep disorders
-low appetite, growth retardation + weight loss
-monitor pulse, BP, psychiatric symp, appetite, weight + weight at initiation, following dose adjustments *6MT
92
lisdexamfetamine + dexamfetamine
-similar S/E to methylphenidate
-overdose causes wakefulness, excessive activity, paranoia, hallucinations, hypertension followed by exhaustion, convulsions, hyperthermia, coma
-similar monitoring as methylphenidate
93
alcohol dependence mild tx
- no assistance needed
94
alcohol dependence moderate tx
- community tx unless at high risk of developing alcohol withdrawal seizures or delirium
95
alcohol dependence severe tx
-undergo withdrawal in inpatient setting
96
alcohol dependence tx
- CBT or with acamprosate or naltrexone (alternate; disulfiram)
-withdrawal symptoms; long-acting benzodiazepine = chlordiazepoxide or diazepam ( alternate; carbamazepine or clomethiazole)
-delirium; lorazepam
- wernick's encephalopathy; thiamine (vit b12)
97
nicotine dependence tx
-varenicline
-> avoid in epilepsy, cardiovascular disease + psychiatric illness
-bupropion
-> avoid in psychiatric illness, seizures, eating disorders
->causes serotonin syndrome
-NRT
->use as a patch 6HR if pregn/nightmares AND use short term reliever - lozenges, gum, sublingual tabs, inhalator, nasal spray or oral spray
98
opioid dependance tx
-under qualified prescriber supervision
-prescribed on FP10MDA max 14DY supply
-three or more missed doses - specialist
-tx continue through pregn
-naloxone - prescribed if high risk of overdose
-buprenorphine
->less sedating than methadone
->milder withdrawal symp
-> lower risk of overdose
->substance (buprenorphine with naloxone) when risk of injecting
-methadone
-> causes QT prolongation
-> carefully titrated according to pt needs
99
migraines
unilateral, pulsating, severe enough to affect daily activities, freq accompained by N+V, phtophobia + phonophobia
100
migraines with aura
-precede most at onset of headache
-visual symp (zigzag, flickering lights, spots, lines)
-sensory symp (pins + needles, numbness)
-dsyphagsia
101
migraines with aura lifestyle advice
-maintain hydration, sleep, exercise
-avoid choco + wine
-relax after stress
-headaches diary = useful triggers
102
migraines with aura acute tx
-aspirin, ibuprofen, 5HTI-receptor agonist - sumatriptan
-asap when symp start
-with aura = triptan/start of headaches x aura
-triptan can be repeated 2hr (4hr-naratriptin) only if response to 1st dose x adequate
-soluble paracetamol if x favorable
-antiemetics - metoclopramide or prochlorperazine
103
migraine prophylaxis
-1st line: propranolol (CI then metoprolol/nadolol)
-amitriptyline effective if sedating use less sedating TCA or not tolerated
-sodium valproate, pizotifen, botox = specialist
104
cluster headache
-intense unilateral pain or around one eye
-acute; SC sumatriptan (nasal sumatriptan/zolmitriptan if unavailable)
-prophylaxis; verapamil, lithium, prednisolone or ergotamine tartate
105
trigeminal neuralgia
severe facial pain = electrical shock in jaw, teeth or gums
tx- carbamazepine
106
tension headache
-bilateral throbbing pain like tight band around head
-tx- paracetamol or ibuprofen
107
N+V tx
antihistamines = cyclizine + promethazine or phenothiazines (prochlorperazines) are usual tx in prophylaxis or tx of N+V
108
N+V tx pregn
avoid drug therapy use promethazine if needed
109
N+V tx post-op
5HT3-receptor antagonist ondansetron or dexamethasone
110
N+V tx pre-op
lorazepam
111
N+V tx motion sickness
hyoscine hydrobromide
112
N+V tx terminal illness
antipsychotics (haloperidol + levomepromazine)
113
N+V tx parkinsons
domperidone
114
domperidone
-x cross blood barrier brain so ideal in parkisons
-10mg TDS
-12YR+
-7DY only
-35kg+ can cause QT prolongation
115
metoclopramide
-can cause extrapyramidal s/e = x parkinsons
-10mg TDS
-min 18yr
-5DY max use
116
mild pain tx
-non-opiates paracetamol, ibuprofen, NSAID, aspirin
117
mild to moderate pain tx
-weak opiates; codeine/dihydrocodiene
-moderate ; tramadol (less seizure threshold, serotonin syndrome, high risk of bleed, psychiatric disorders)
118
moderate - severe pain tx
-strong opiates; morphine, oxycodone, methadone, buprenorphine, fentanyl
119
codeine
-12yr+
-x children <18 - tonsils removed due to sleep apnea
- x pt - ultra rapid metaboliser (Afro-Caribbean) toxicity
- x breastfeeding
120
opiate s/e
-act on mu-pathway causing
-dry mouth
-constipation
-CNS depression
-N+V
-hypotension
-miosis (pupil constriction)
121
strong opiates
-prolonged use; hypogonadism, adrenal insufficiency, hyperglyesia
-overdose; use naloxene
-aovid in paralytic ileus, respiratory disease + head injury
-breakthroguh pain 1/6th to 1/10th total daily dose evety 2-4hr
-inc opiate doses by 1/2 to 1/3 each day
-dec doses to 1/2 to 1/3 when switching to x overdose
-oxycodone more potent than morphine = more appropriate in pt x consume large amounts due to nausea
-patches avoid exposure to heat, apply to dry, hairless skin + rotate area
-fentanyl; remove patch immediately if toxicity signs
122
neuropathic pain tx
-TCA = amitriptyline, nortriptyline
-antiepileptics = gabapentin, pregabalin
-opiates = morphine/oxycodone
-topical localised = lidocaine/capsaicin
123
main two types of focal seizures
-focal aware seizures
-focal impaired awareness seizures
124
focal aware seizures
-general strange feeling hard to describe
-rising feel in stomach (ride feeling)
-deja vu
-unusual smell or taste
-tingling sensations in arms/legs
-sudden feeling or fear or joy
-twitching or stiffness in arm or hand
-these are = warning/aura to show another type of seizure on way
125
focal impaired awareness seizures
-lose sense of awareness - won't remember what happened after
-random bodily behaviour
->smacking lips
->rubbing hands
->random noises
->moving arms around
->picking at clothes
->fiddling with objects
->adopting an unusual posture
-> chewing or swallowing
-> wont be able to respond to anyone
