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Pre reg pharmacy > CNS > Flashcards

CNS Flashcards

1
Q

Focal seizure treatment

A

First line - lamotrigine/ levetiracetam
Second line - Carbamazepi, oxcarbazepine, zonisamide

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2
Q

Generalised tonic clonic treatment

A

First line - Sodium valproate
Second line - lamotrigine/ levetiracetam

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3
Q

Absence seizure treatment’s

A

First line - Ethosuximide
Second line - sodium valproate

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4
Q

Absence seizure with other

A

First line - sodium valproate
Second line - lamotrigine/ levetiracetam

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5
Q

Myoclonic treatment

A

Sodium valproate
Second line- levetiracetam

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6
Q

Atonic seizure treatment

A

First line - sodium valproate
Second line - lamotrigine

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7
Q

Tonic seizure treatment

A

First line - sodium valproate
Second line - lamotrigine

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8
Q

Treatment of status epilepticus

A
  1. IV lorazepam (if resuss available/ buccaneers midazolam/ rectal diazepam
  2. Second dose if seizure not stopped within 5-10 mins
  3. Levetiracetam/ phenytoin/ sodium valproate
  4. Try another of the 3
  5. Phenobarbital / general anaesthetic if no response still
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9
Q

Category 1 Antiepileptics

A

Carbamazepine, phenytoin, phenobarbital, primidone
Maintain brands

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10
Q

Category 2 Antiepileptic drugs

A

Clobazam, clonazepam, lamotrigine, oxcarbazepine, perampanel, topiramate, rufinamide, valproate, zonisamide
Use clinical judgement for brands

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11
Q

Category 3 Antiepileptic drugs

A

Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin

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12
Q

Carbamazepine, phenytoin, sodium valproate drug interactions

A
  1. Hepatotoxicity - Amiodarone, itraconazole, macrolides, alcohol
  2. CYP enzyme - INDUCERS; Phenytoin, phenobarbital, carbamazepine/ INHIBITORS sodium valproate
  3. Lower seizure threshold - tramadol, theophylline, quinolones
    CARBAMAZEPINE & hyponatraemic - ssri, diuretics
    PHENYTOIN &Antifolates - methotrexate, trimethoprim
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13
Q

Carbamazepine, phenytoin, valproate side effects

A

Depression, suicide, hepatotoxic, hypersensitivity, blood dyscrasia, vit D deficiency (bone pain)
CARBAMAZEPINE: oedema, hyponatraemia
Phenytoin: coarsen appearance, face hair
Sodium valproate: teratogenic ! Pancreatitis

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14
Q

Antiepileptics likely to cause hypersensitivity

A

Category 1 & lamotrigine

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15
Q

Antiepileptics likely to cause skin rash

A

Lamotrigine ( Steven Johnson’s syndrome )

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16
Q

Antiepileptics likely to cause blood dyscrasia (C.VET.PLZ)

A

Carbamazepine, valproate , ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide

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17
Q

Antiepileptics likely to cause eye disorders

A

Topiramate ( secondary glaucoma)
Vigabatrin (reduced field)

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18
Q

Antiepileptics likely to cause encephalopathy

A

Vigabatrin

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19
Q

Antiepileptics likely to cause respiratory depression

A

Gabapentin, pregabalin

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20
Q

Therapeutic range of carbamazepine

A

4-12mg/L

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21
Q

Signs of carbamazepine toxicity (HANDBAG)

A

Hyponatraemia, Ataxia, nystagmus, drowsiness, blurred vision, GI disturbance

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22
Q

Phenytoin therapeutic range

A

10-12mg/L

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23
Q

Signs of phenytoin toxicity (SNACHD)

A

Slurred speech,Nystagmus, ataxia, confusion, hyperglycaemia, double vision

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24
Q

Driving after unprovoked/ single seizure

A

Notify DVLA, leave 6 months

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25
Q

Driving after established epilepsy

A

1yr/ pattern of seizures established over 1 yr with no impact on consciousness

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26
Q

Driving after Antiepileptics med change/ withdrawal

A

At least 6 months after dose change
If seizure occurs; license revoked for 1yr, reinstate after y months if treatment resumed and no further seizures

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27
Q

Antiepileptics high presence in breast milk (PELZ)

A

Primidone, ethosuximide, lamotrigine, zonisamide

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28
Q

Antiepileptics with risk of drowsiness in breast milk (PPB)

A

Phenobarbital, primidone, benzodiazepines

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29
Q

Antiepileptics with breast milk withdrawal effects if sudden stop (PPBL)

A

Phenobarbital, primidone, benzodiazepines, lamotrigine

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30
Q

Bipolar acute treatment

A

Benzodiazepines/ Antipsychotics ( quetiapine, olanzapine, risperidone)
Add ons - lithium/ sodium valproate

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31
Q

Managing mania/ hypomania in bipolar

A
  1. Stop antidepressant & start antipsychotic (olanzapine, risperidone, quetiapine)
  2. Try alternative antipsychotic
  3. Lithium
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32
Q

Managing depression in bipolar

A
  1. Psycho intervention
    Mod - severe ; Fluoxetine & olanzapine, quetiapine, lamotrigine
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33
Q

Managing bipolar disorder long term

A
  1. Lithium
  2. Antipsychotic
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34
Q

Lithium therapeutic range

A

0.4-1mmol/L (0.8-1mmol/L acute)

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35
Q

Frequency of lithium monitoring

A

12 hours after dose, weekly till stable for first year then 6 monthly

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36
Q

Signs of lithium toxicity (REVNG)

A

Renal impairment/incontinence, extra pyramid tremors, visual disturbance (blurred), nervous system (confusion/restless), gi disorders (diarrhoea, vomit)
SICK & TREMOR

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37
Q

Lithium side effects

A

Thyroid disorders, nephrotoxicity, rhabdomyolysis, Qt prolongation, benign intracranial hypotension

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38
Q

Lithium interactions

A

Hyponatraemia (increase risk of toxicity ) - diuretics
Salt imbalance
Serotonin syndrome - ssri, tca
Extrapyramidal side effects - metoclopramide! Haloperidol
Qt prolongation - tramadol, theophylline
Re ally cleared drugs (increase toxicity)
Reduce seizure threshold
Hypokalaemia

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39
Q

Treatment of mild-mod dementia

A

Acetycholinesterase inhibitors; donepezil, rivastigmine, galantamine

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40
Q

Treatment of mod- severe dementia

A

Memantine

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41
Q

Treatment of aggravation in dementia

A

Benzodiazepines/ antipsychotic

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42
Q

Side effects of increased acetylcholine (DUMBBELS)

A

Diarrhoea, urinary incontinence, muscle weakness, bradycardia, bronchospasm, emesis, lacrimation, salivating

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43
Q

Treatment for Parkinson’s if motor symptoms decrease QOL

A

Levodopa + carbidopa/benserazide

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44
Q

Treatment for Parkinson’s if motor symptoms don’t effect QOL

A

Levodopa, non-ergot DA receptor, MAO-B Inhibitors

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45
Q

Action of carbidopa or benserazide

A

Prevent breakdown of levodopa before crossing BBB

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46
Q

Side effects of levodopa

A

Impulse disorders, sudden onset of sleep (treat with modalafil), red urine

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47
Q

Non- ergot derived DA receptor

A

Pramipexole, ropinirole, rotigotine

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48
Q

Non ergot da receptor side effects

A

Impulse disorders, sudden onset of sleep, hypotension

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49
Q

MAO-B Inhibitors

A

, selegiline, rasagiline

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50
Q

MAO-I interactions

A

Phenylephrine (hypertensive crisis)
Tyramine rich foods

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51
Q

Parkinson’s progression despite optimum levodopa

A

ADD non-ergot da receptor, mao b inhibitor, COMT inhibitors

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52
Q

COMT inhibitor side effects

A

Entacapone - red urine
Tolcapone - hepatotoxic
Increase sympathomimetic side effects- increased cvd

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53
Q

Nocturnal akinesia treatment

A
  1. Levodopa/ da receptor
  2. Rotigotine
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54
Q

Parkinson’s symptoms not fully controlled by adjunct non ergot

A

Ergot derived - bromocriptine, cabergoline

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55
Q

First gen (phenothiazines) antipsychotic GROUP 1

A

PROMAZINES; MOST sedation, MODERATE antimuscarinic, extra pyramid
Chlorpromazine, levopromazine, promazine

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56
Q

First gen group 2 phenothiazine antipsychotic (cyazine)

A

Pericyazine
MODERATE sedation LEAST extra pyramid

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57
Q

First gen group 3 phenothiazines antipsychotic (azines)

A

MOST extra pyramid, MODERATE sedation
Fluphenazine, prochlorperazine, trifluperazine

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58
Q

First gen butyrophenone antipsychotic (PERIDOLS)

A

Benperidol, haloperidol
SIMILAR TO GROUP 3- HIGH extra pyramid, MODERATE sedation

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59
Q

First gen thioxanthenes antipsychotic (PENTIXOL)

A

Flupentixol, zuclopenthiol
Moderate sedation - antimuscarinic AND extra pyramid

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60
Q

First gen other antipsychotic

A

Primozide, sulpride
Reduced sedation, antimuscarinic AND extra pyramidal

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61
Q

Antipsychotic monitoring weight

A

At start, weekly for first 6 weeks! At 12 weeks, 1 yr then annual

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62
Q

Antipsychotic blood glucose monitoring frequency

A

At start, as wks, 1 yr then annual

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63
Q

Antipsychotic BP monitoring

A

Start, at 12wks, 1 yr, annual

64
Q

When to use clozapine

A

Resistant schizophrenia.
Only when 2+ antipsychotic used inc 1 second gen 6-8wks each

65
Q

Clozapine monitoring

A

Leukocytes and differential blood count
Weekly for 18 weeks, fortnightly till 1 yr then monthly

66
Q

Clozapine side effects

A

Myocarditis + cardiomyopathy - report + stop on tachycardia
Agranulocytoses and neutropenia - monitor
Gi - resport + stop in constipation

67
Q

How many missed clozapine doses does it take to refer to specialist and retitrate

A

2+

68
Q

Treatment of acute anxiety

A

Benzodiazepines - shortest course, lowest dose

69
Q

Treatment of chronic anxiety

A

Ssri
Propranolol - alleviate physical symptoms

70
Q

Long acting benzodiazepines

A

Diazepam, alprazolam, chlordiazepoxide,
Higher hangover effect
Also used in sleep maintenance

71
Q

Short acting benzodiazepines

A

Lorazepam, oxazepam
Preferred in elderly and hepatic impairment
Higher risk of withdrawal symptoms (2-4 wks)
Little-no hangover effect
Also used for sleep onset

72
Q

Benzodiazepines side effects

A

Paradoxical - aggression, hostility, talkative, anxious, excited

73
Q

Treatment of benzodiazepine overdose

A

Flumazenil

74
Q

Benzodiazepines with legal driving limit

A

Clonazepam, oxazepam, lorazepam, diazepam, flunitrazepam, temazepam

75
Q

Benzodiazepines withdrawal effects

A

Anxiety, sweating, weight loss, tremors, loss of appetite

76
Q

Benzodiazepines withdrawal treatment

A
  1. Convert all to ON diazepam
    2.Reduce by 1-2mg (1/10th of large dose) every 2-4wks
  2. Reduce 0.5mg towards end
77
Q

Treatment option for mild depression

A

CBT

78
Q

Treatment of mod- severe depression

A
  1. SSRI
  2. increase dose/ change SSRI/ mirtazapine, MAO-I (specialist)/ TCA/ venlafaxine
  3. Second line doesn’t work - add another class/ lithium/ antipsychotic
  4. Electroconvulsive for severe refractory
79
Q

SSRI side effects

A

GI disturbance
Appetite/ weight gain
Sexual dysfunction
Risk of bleed
Insomnia ( take in morning)
QT prolongation (citalopram/ escitalopram)

80
Q

SSRI Interactions

A

CYP enzyme inhibitors - (grapefruit) increase plasma con
CYP enzyme inducers - reduce effectiveness
Drugs inducing risk of bleed
Hyponatraemia
Serotonin syndrome

81
Q

Sedating TCA better for agitated or anxious

A

Amitriptyline, clomipramine, dosulepin, trazadone

82
Q

Less sedating TCA

A

Imipramine, nortriptyline, lofepramine

83
Q

TCA side effects (CASHH)

A

Cardiac events
Antimuscarinic
Seizures
Hypotension
Hallucinations

84
Q

TCA Interactions

A

CYP inhibitors- grapefruit, reduce effectiveness
CYP inducers -reduce effectiveness
QT prolongation - amiodarone, Sotolol, quinolones
Antimuscarinic drugs
Anti hypertension

85
Q

MAO-I interactions

A

Hepatotoxic - phenelzine, isocarboxazid
Hypertensive crisis -ephedrine
Tyramine rich foods
Tranylcypromine
Clomipramine

86
Q

How long till antidepressants can be started after MAOI

A

2wks, 3wks clomipramine /imipramine

87
Q

How long between MAOI

A

2 wks, 0 moclobemide

88
Q

How long after TCA/ related to start MAOI

A

1-2wks / 3wks in clomipramine/imipramine

89
Q

How long after SSRI to start MAOI

A

1wk , 5wks in fluoxetine

90
Q

Cause of transient insomnia

A

Noise, shift work, jet lag

91
Q

Treatment of transient insomnia

A

Rapidly eliminating hypnotic (1/2 doses)

92
Q

Z hypnotics dependence period

A

3-14days

93
Q

Z hypnotic dose restrictions

A

Intermittent doses, max 4 wks treatment

94
Q

Z drug side effects

A

Drowsiness, dependence and paradoxical side effects

95
Q

ADHD treatment regimen 5yrs+

A
  1. Methylphenidate
  2. If 6 wk trial at max dose doesn’t reduce symptoms - lisdexamfetamine/ dexamfetamine if lis not tolerable
  3. Atomoxetine/ guanfacin if neither tolerated
96
Q

Methylphenidate side effects

A

Cardiac - high blood, tachycardia, arrhythmia
CNS - behaviours change, drowsiness, sleep disorders
Decreased appetite, growth retardation, weight loss

97
Q

Methylphenidate monitoring factors

A

Pulse, BP, psychiatric symptoms, appetite, weight, height

98
Q

Methylphenidate monitoring frequency

A

At initiation then 6 monthly

99
Q

Lisdexamphetamine OD symptoms

A

Wakefulness, excessive activity, paranoia, hallucinations, hypertension
Followed by - exhaustion, convulsions, hyperthermia, coma

100
Q

Alcohol dependence withdrawal setting

A

Mild - usually don’t need assisted withdrawal
Mod - community unless high risk of seizure/delirium
Severe - inpatient withdrawal

101
Q

Alcohol dependence first line treatment

A

CBT or acamprosate/ naltrexone

102
Q

Alcohol dependence second line treatment

A

Disulfram

103
Q

Treatment of alcohol withdrawal symptoms

A

Long acting benzodiazepines (chlordiazepoxide/diazepam)
Alternative - carbamazepine/ clomethiazole

104
Q

Treatment of alcohol withdrawal delirium

A

Lorazepam

105
Q

Treatment of wernicke’s encephalopathy

A

Thiamine (vit b1)

106
Q

Nicotine replacement therapy

A

Patches - use 16hr in pregnancy and nightmares
AND
Short term reliever

107
Q

Varenicline contraindications

A

Epilepsy, CVD, psychiatric illness

108
Q

Bupropion contraindications

A

Avoid in psychiatric illness, seizures, eating disorders, serotonin syndrome

109
Q

When to use Naloxone

A

Pts at high risk of opioid overdose

110
Q

Length of initial supervised consumption in substance dependence and when to start

A

3 months, restarting after break, dose increase

111
Q

Which treatment for patients continuing elicit drug use

A

Methadone

112
Q

Methadone initial dose

A

10-30mg - tolerance not known = 10-20mg

113
Q

Switching between buprenorphine and methadoone

A

Methadone to buprenorphine - reduce gradual then start buprenorphine after start of withdrawal symptoms
Buprenorphine to methadone - start 24hrs after last dose

114
Q

Migraine lifestyle advise

A

Maintain hydration, sleep, exercise
Avoid chocolate and wine
Relax after stress
Headache diary to identify triggers

115
Q

Acute migraine treatment

A

Aspirin, ibuprofen, 5HT1 agonist

116
Q

Treatment of migraine with aura

A

Triptan (at start of headache not aura)

117
Q

When to repeat Triptan dose

A

Repeat after 2hrs if first dose gives some response but not adequate

118
Q

Second line migraine treatment

A

Soluble paracetamol

119
Q

Antiemetics in migraine

A

Metoclopramide/ prochlorperazine

120
Q

First line migraine prophylaxis

A

Propranolol - Metoprolol/nadalol if CI

121
Q

Second line migraine prophylaxis

A

Amitriptyline - less sedating TCA if not tolerated

122
Q

Third line migraine prophylaxis

A

Sodium valproate, pizotfen, Botox - under specialist

123
Q

Acute treatment for cluster headaches

A

SC sumaptriptan (nasal suma/zolmi if unavailable)

124
Q

Prophylaxis of cluster headaches

A

Verapamil, lithium, prednisone, ergotamine

125
Q

Tigeminal neuralgia symptoms

A

Severe facial pain, electric shock like in jaw/teeth/gums

126
Q

Tigemenial neuralgia treatment

A

Carbamazepine

127
Q

Treatment of tension type headache

A

Paracetamol / ibuprofen

128
Q

Nausea and vomiting treatment in preganancy

A

Promethazine if needed but avoid where possible

129
Q

Nausea and vomiting in post op treatment

A

5HT3 receptor antagonist - Ondansetron OR dexamethasone

130
Q

Treatment of pre op nausea and vomiting

A

Lorazepam

131
Q

Motion sickness treatment

A

Hyoscine hydrobromide

132
Q

Nausea and vomiting palliative treatment

A

Haloperidol / levomepromazine

133
Q

Treatment for Nausea and vomiting in Parkinson’s disease

A

Domperidone - doesn’t cross BBB

134
Q

Minimum age for domperidone

A

12yrs

135
Q

Maximum treatment length for domperidone

A

7 days

136
Q

Minimum weight for domperidone treatment

A

35kg

137
Q

Side effects of metoclopramide

A

Extra pyramidal - avoid in Parkinson’s

138
Q

Minimum age of metoclopramide

A

18yrs

139
Q

Maximum treatment length of metoclopramide

A

5 days

140
Q

Treatment of mild pain

A

Non-opiates - paracetamol, NSAIDs, aspirin

141
Q

Treatment of Mild-moderate pain

A

Weak opioids - codeine, dihydrocodeine
Moderate - Tramadol

142
Q

Tramadol side effects

A

Low seizure threshold, serotonin syndrome, increased risk of bleeding , psychiatric disorders

143
Q

Treatment of moderate to severe pain

A

Strong opiates - morphine, oxycodone, methadone, buprenorphine, fentanyl

144
Q

Minimum age of codeine

A

12 yrs, 18yrs if tonsils removed

145
Q

Who should avoid codeine

A

Ultra metabolisers
Breastfeeding

146
Q

Opiate side effects

A

Dry mouth, constipation, CNS depression, nausea and vomiting, hypotension, miosis (pupil constriction)

147
Q

Risks of long term use of opiates

A

Hypogonadism, adrenal insufficiency, hyperalgesia

148
Q

Opioid overdose treatment

A

Naloxone

149
Q

When to avoid opiates

A

Paralytic ileus, respiratory disease, head injury

150
Q

Opioid patch use

A

Avoid exposure to heat
Apply to dry and hairless area
Rotate site

151
Q

Treatment of neuropathic pain

A

TCA - Amitriptyline, nortriptyline
Antiepileptics - Gabapentin/ pregabalin
Opiates - Tramadol, morphine, oxycodone,
Topical - lidocaine, capsaicin

152
Q

Treatment of spasticity in multiple sclerosis

A

Baclofen, diazepam, tizanidine, dantrolene

153
Q

Treatment of relapse in multiple sclerosis

A

Methylprednisolone

154
Q

Treatment of oscillopsia in multiple sclerosis

A

Gabapentin

155
Q

Treatment for mood in multiple sclerosis

A

Amitriptyline

156
Q

treatment for fatigue in multiple sclerosis

A

Amanda dine/fampridine

Pre reg pharmacy (4 decks)

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