CNS Flashcards
1
Q
What drugs are used for nausea and vomiting in pregnancy
A
- Cyclizine
- Metoclopramide or Prochlorperazine
2
Q
What is used in motion sickness
A
- Hyoscine hydrobromide
- Promethazine if sedative effect required (or cyclizine / cinnarizine)
3
Q
What is used in post operative nausea and vomiting
A
- Ondanseron
- Dexamethasone
- Droperidol & haloperidol
- Prochloperazine
- Cyclizine - N&V caused by opioid or general anaesthetics
4
Q
Side effect of domepridone
A
Risk of cardiac side effects
Max treatment duration should not exceed 7 days
5
Q
Side effect of metoclopramide
A
Risk of neurological adverse effects
Short term use up to 5 days
6
Q
What age can Promethazine not be sold OTC
A
Children < 6 yrs for cough and cold
7
Q
Pain ladder
A
Step 1: Mild pain
- Non-opiods - paracetamol, aspirin, NSAIDs
Step 2: Mild to Moderate pain
- Weak opioids - codeine, tramadol
Step 3: Moderate to Severe
- Strong opioid - morphine, oxycodone, methadone, fentanyl
Adjuvants:
• neuropathic pain → TCA, gabapentin / pregablin
• bone metastases → bisphosphonates, strontium ranelate
• nerve compression by tumors → dexamethasone
8
Q
What is used in mild to moderate Alzheimer’s
A
- Donepazil
- Galantamine
- Rivastigmine
9
Q
What is used in severe Alzheimer’s
A
Memantine
10
Q
What is used in non-alzheimer’s with lewy bodies
A
Donepazil
Rivastigmine
If not tolerated: galantamine
11
Q
What is used in severe dementia with Lewy bodies
A
Donepazil
Rivastigmine
12
Q
What is used to treat extreme violence, aggression and agitation in dementia
A
- Oral IM haloperidol
- Olanzapine
- Lorazepam
13
Q
What is used in dementia with Lewy body (Parkinson’s disease)
A
Rivastigmine
14
Q
Can you use Acetylcholine inhibitors and memantine in pts with frontotemporal dementia or cognitive impairment caused by sclerosis
A
No
15
Q
Side effect associated with Donezapil
A
Neuroleptic malignant syndrome
high fever, sweating, unstable blood pressure
16
Q
Side effect associated with Rivastigmine
A
- Dehydration
- GI side effects - STOP/ Switch to patch
17
Q
When to stop Rivastigmine
A
GI side effects
switch to patch
18
Q
Side effect of Galantamine
A
Stevens Johnson’s Syndrome
19
Q
How do we treat Focal seizures
A
- 1st: Lamotrigine or Levetiractem
- 2nd: Carbamazapine. Oxcabazepine, zonisamide
20
Q
How do we treat Tonic-clonic seizures
A
Valporate Alt. Lamotrigine or Levetiracetam
21
Q
How do we treat Absence seizures
A
Ethosuximide or Valporate
Alt. Lamotrigine or Levetiracetam
22
Q
How do we treat Myoclonic seizures
A
Valporate Alt. Topiramate, Levetiracetam
23
Q
How do we treat Atonic/tonic seizures
A
Valporate Alt. Lamotrigine
24
Q
What are category 1 anti-epileptic drugs
A
’CP3’
- Carbamazepine
- Phenytoin
- Phenobarbital
- Primidone
Prescribed by brand
25
What are category 2 anti-epileptic drugs
‘**TV** **L**oan @ **C**urrys’
- Valporate
- Lamotrigine
- Clonazepam
- Topiramate
26
What are category 3 anti-epileptic drugs
- Levetiractem
- Gabapebtin
- Pregablin
- Ethosuximide
27
How are anti-epileptic drugs withdrawn
- Gradually reduce dose with supervision
- avoid abrupt withdrawal
- withdraw one drug at a time
28
How long is the driving ban after last dose of anti-epeleptic (withdrawal)
6 months
29
How long is the driving ban after first unprovoked seizure
- normal car
- large vehicles
- 6 months
- 5 years for large vehicles
30
How long must patient be seizure free to drive
1 year
31
How long are patients not allowed to drive for if they have seizures while asleep
1 year
32
How long are patients not allowed to drive for if they have seizures while asleep and awake
3 years
33
What anti epileptic are associated with anti epileptic hypersensitivity syndrome
‘**CP3RLOL**’
- carbamazepine
- phenobarbital
- phenytoin
- Primidone
- rufinamide
- lamotrigine
- oxcarbazepine
- lacosamide
34
MHRA warning with antiepileptics
Suicidal thoughts
35
Antiepileptic drugs with highest teratogenic risk
Valproate
36
Antiepileptic with increased risk of teratogenicity
**'CP3'**
- carbamazepine
- phenytoin
- Phenobarbital
- primidone
37
Which drug is associated with cleft palate
Topiramate *(1st trimester)*
38
What antiepileptic drugs require monitoring of fatal growth
**tira**
Leve**tira**cetam and **t**op**ira**mate
39
What dose and duration should folic acid be given to women at high risk of conceiving a child with neural tube defects
5 mg OD
*before conception and until 12th week*
40
Withdrawal effects in new-borns occur more with?
Benzodiazepines and phenobarbital
41
What antiepileptics are found in high concentration in breast milk
‘**ZELP**’
- zosinamide
- ethosuximide
- lamotrigine
- primidone
42
What antiepileptics accumulate in infants
Lamotrigine
Phenobarbital
43
What antiepileptics inhibit sucking reflex
Phenobarbital
Primodine
44
Symptoms of antiepileptic hypersensitivity syndrome
• what to do if this occurs?
Rash, fever, lymphadenopathy, systemic involvement
- occurs in first 1-8 weeks of starting
- discontinue immediately
45
Which antiepileptic is associated with severe skin reactions especially in children
Lamotirigine
46
What drug increases lamotrigine side effects and why?
Sodium valproate
*Enzyme inhibitor so increases concentration of lamotrigine*
47
What two antiepileptics are at risk of cross-sensitivity
Carbamezapin
Phenytoin
48
Side effect of gabapentin
Severe respiratory depression
49
What antiepileptics are associated with blood dyscrasias
**’C Vet Plz’**
- carbamazepine
- valproate
- ethosuximide
- topiramate
- phenytoin
- lamotrigine
- zonisamide
*report signs of infection, bruising, bleeding*
50
What antiepileptics are associated with eye problems
Vigabatrin
Topiramate
51
What antiepileptics are associated with encephalopathic symptoms
*sedation, super and confusions*
Vigabatrin
Topiramate
Valproate
52
Nature of interaction between valproate and digoxin
Increase plasma conc.
Increased toxicity
53
Nature of interaction between carbamazepine and phenytoin
Decreased concentration of carbamazepine
54
What is used to treat Diavet syndrome
**Valporate**
OR
‘**CVS**’
Clobazam + valproate + stiripentol
55
Which anetylchorinesterase inhibitor is avoided in hepatic and renal impairment <9ml/min
Galantine
56
What are the acteyl chloringenic side effects?
*dementia drugs*
**'Dumbbels'**
Diarrhoea
Urination
Muscle cramps
Bronchospasm
Bradycardia
Emesis (vomiting)
Lacrimation (teary eyes)
Salivation / sweating
57
Monitoring requirement for rivastigmine
Body weight
58
Side effect of memantine
Constipation
59
When to avoid phenytoin
- Absence seizures
- myoclonic seizures
*Exarcebates*
60
Therapeutic range of phenytoin
**10-20 mg/L**
6 -15 mg/l in neonates
61
What to look out for in phenytoin toxicity
‘**SNACHD**’
- slurred speech
- nystagmus (uncontrolled eye movement)
- ataxia (lack of voluntary coordination of movement)
- confusion
- hyp**ER**glycaemia
- diploma (double vision), blurred vision
62
Side effects of phenytoin
Long term: change in appearance
- low vitamin D
- hepatic toxicity
63
When to discontinue phenytoin
Signs of liver toxicity
64
Nature of interaction between phenytoin and Amiodarone
Increase concentration of phenytoin
65
Nature of interaction: phenytoin and St. John's wort
Decrease concentration of phenytoin
66
Nature of interaction: phenytoin and quinones
Anticonvulsant effect antagonised
67
Nature of interaction: phenytoin and contraceptives
Reduce plasma conc. Of contraceptive
68
When to avoid carbamazepine
- atonic seizure
- clonic seizure
- myoclonic seizure
69
Therapeutic range of carbamazepine
4-12 mg/l
Monitor after 1-2 weeks
70
Signs of toxicity with carbamazepine
‘**I HANDBAG**'
- inco-coordination
- hyp**ON**atraemia
- ataxia
- nystagmus
- drowsiness
- blurred vision
- arrhythmias
- gastro - intestinal disturbance
71
Nature of interaction: carbamerapine and SSRI
Hyponatramia
72
Nature of interaction: carbamerapine and valproate
Hepatotoxicity
73
Nature of interaction: carbamerapine and fluoxetine
Increase conc. Of carbamazepine
74
How often should liver function be monitored with valproate
Every 6 months
75
How is status epilepticus treated
• Urgently with **lV lorazepam**
• repeat once after 10 minutes if no response
Rectal Diazepam or buccal mudazolam - community
76
What is avoided in status epilepticus
IV diazepam
77
If patient has a seizure after treatment with benzodiazepine in status epilepticus, what should be given?
‘**Ph=F**’
- phenytoin
- Phenobarbital
- fosphenytoin
78
What is given first line in febrile convulsions
Paracetamol
79
What is used to treat convulsive seizures of febrile convulsions lasting more than 5 minutes in community setting
- Diazepam rectally
- midazolam solution (in the buccal cavity)
*Repeat once after 10-15 minutes if necessary*
80
What is used in chronic anxiety?
Antidepressant (SSRI)
81
What are the hypnotic drugs
- Benzodiazepines
- z-drugs
- chlomethiazole
- promethazine
- melatonin
82
Examples of benzodiazepines
Lorazepam
Diazepam
83
Benzodiazepines metabolised by the liver
‘**F**ound **A** **CD** in the liver**’
- Florazepam
- alprazolam
- cholerdiazepoxide
- diazepam
84
What benzodiazepines are not affected by the liver
‘This **LOT** are not metabolised by liver’
- lorazepam
- Oxazepam
- temazepam
85
Side effect of benzodiazepine in elderly
Hypotension
86
Benzodiazepine in pregnancy
Neonatal depression (floppy syndrome)
87
When are benzodiazepines contraindicated
Respiratory distressed patients
88
Benzodiazepine and alcohol
Enhances side effects
89
What route can't Benzos be given
Intramuscularly - eratic absorption at site
90
What antiemetic is given for chemically induced nausea and vomiting (most drugs including opioids)
**Haloperidol**
Oral: 1.5mg ON/BD, titrate up to a max of 10mg daily
91
How is oxycodone immediate release prescribed?
QDS
92
What is used to test for cognitive impairment
MMSE
MoCA
93
Side effects of valproate
GI
Weight gain
94
What electrolyte imbalance puts patient at high risk of lithium toxicity
Hyp**ON**atraemia - low sodium
95
Side effect of benzodiazepines and z-drugs (urine)
Reduce awareness of the need to urinate
96
Drugs that have antimuscarinic effects (anticholinergic)
- **Tricyclic Antidepressants** *(eg. Amitriptyline, dosulepin)*
- **Antihistamines** *(eg. Chlorphenamine and Promethazine)
- **Antipsychotic** *(eg. Olanzapine and quetiapine)*
- **Urinary antispasmodic** *(eg. Solifenacin and tolterodine)*
97
When should rivastigmine be reviewed
Dehydration resulting from prolonged vomiting or diarrhoea
98
Antipsychotic and elderly dementia patients
MHRA: increased risk of stroke and small increased risk of death
99
What class and schedule are gabapentin and pregabalin
Class 3 Schedule 3
100
Nature of interaction: phenytoin and anti-folate
*Methotrexate and trimethoprim*
**Increased anti-folate effect**
101
Side effects of benzodiazepines
- Paradoxical increase in hostility and aggression
- Sedation
- Dependence
102
Signs of benzodiazepines overdose
- Ataxia
- Nystagmus
- Drowsiness
- Respiratory depression
- Coma
- Hangover effect when taken at night
103
What is used to treat benzodiazepine poisoning
Flumenazel
104
Withdrawal process of benzodiazepines
1. Transfer to equivalent **daily dose of diazepam** preferably taken at night *for **1 week***
2. Reduce diazepam dose by **1-2mg every 2-4 weeks**
3. Reduce the dose further then stop
*Withdrawal symptoms for long term users usually resolve within 6-18 months of the last dose*
105
What benzodiazepine is used in conscious sedation in dental procedures
Temazepam
106
Examples of barbiturates
Phenobarbital
Pentobarbital
Secobarbital
107
Short acting barbiturates
‘**SecPen**’
- Secobarbital
- Pentobarbital
108
Long acting barbiturates
**’Phen’**
- Phenobarbital
- Phenobarbitone
109
When is barbiturates not recommended
Insomnia
110
Main use of barbiturates
Sedation and hypnosis
111
Side effect of phenobarbitone
Neonatal jaundice
Anticonvulsant effects
112
Adverse effects of barbiturates
- **CNS depression** - drowsiness, respiratory depression
- **Hypersensitivity** - skin rash, itching
- **Acute intermittent porphyria** - severe pain, digestive problems, **red/brown urine**, mental changes
113
What are Z-drugs licensed for
Only Insomnia
114
Main side effect of Z-drugs
Cognitive impairment
Metallic taste in mouth
GI disturbance
115
What are Z drugs
**Short term insomnia**
- Zolpidem
- Zopiclone
- Zaleplon *(shortest acting)*
**Short and long term**
- Eszopiclon
116
Antidote for Z-drug toxicity
Flumezanil
117
What is used to treat ADHD
- behavioural psychotherapy
- Medication
1. **Methylphenidate** + Atomoxetine
2. **Lisdexamfetamine** + Dexamfetamine *(children who don’t respond)*
118
Side effects of ADHD drugs
- Stevens - Johnsons syndrome
- Increased blood pressure and heart rate
119
Adverse effect with ADHD drugs
Tics
Growth impairment
120
When to stop and go to A&E with atomoxetine
Signs of liver failure
121
What class of drug is methylphenidate
CD2
*brand specific for MR preparations*
122
What is the main drug used to treat manic phase
Lithium
123
What anti epileptics can be used in mania
- **Valporate** - acute mania
- **Carbamazepine** - mood stabiliser
124
What are class of antipsychotics are used in mania
2nd generation
125
How long is lithium given as prophylaxis after manic episode
**At least 2 years**
Risk of relapse: 5 years
126
Therapeutic index of lithium
**0.4 to 1 mmol/L** - maintenance and elderly
**0.8 to 1 mmol/L** - acute episodes and relapse
127
Warning signs of lithium toxicity
‘**REV**e**NG**e’
- **R**enal disturbances
- **E**xtrapyramidal symptoms
- **V**isual disturbances
- **N**ervous system disturbances
- **G**astro-intestinal effects
128
Side effects of atomoxetine
- QT prolongation
- Hepatoxicity
- Suicidal ideation
129
What level is lithium considered toxic
> 2 mmol/L
130
When to monitor of lithium plasma conc
- Blood samples taken **12 hours post dose**
- Monitor every **3 months** first year
- Every **6 months** after
131
Monitoring requirements of lithium
**6 monthly**
- Serum concentration
- Renal function
- Thyroid function
- Cardiac function
- BMI
- Electrolytes
- eGFR
132
Side effect of lithium
- Thyroid disorders
- Renal impairment
- Benign inter cranial hypertension
- QT prolongation
- Lowers seizure threshold
- Weight gain
- Muscle weakness
- Hypernatraemia / Hypokalaemia
133
Lithium in pregnancy
Teratogenic
134
Nature of interaction: ACE/ARB + Lithium
Increased toxicity
- **reduced eGFR**
- diarrhoea
135
Nature of interaction: Lithium + SSRI
Increased toxicity
**Risk of seizures**
Serotonin syndrome
136
Nature of interaction: Lithium + NSAID
Increased toxicity
137
Nature of interaction: Lithium + amiodarone
Risk of arrhythmias
138
Nature of interaction: Lithium + Methyldopa
Risk of neurotoxicity
139
Nature of interaction: Lithium + antipsychotics
Risk of EPS effects
140
OTC interaction with lithium
Ibuprofen
Soluble analgesics
Antacids
141
Nature of interaction: Lithium + quinolone
Risk of seizures
142
Nature of interaction: Lithium + antidepressants
Serotonin syndrome
143
Classes of reuptake inhibitors antidepressants
- Tricyclic antidepressant (TCA)
- Selective serotonin reuptake inhibitors (SSRI)
- Serotonin Noradrenaline reuptake inhibitors (SNRI)
- Noradrenaline Dopamine reuptake inhibitors (NDRI)
144
What is used in post operative nausea and vomiting
Ondansetran
145
Examples of TCA
**‘ANTI-DeP-C’** - ‘ine’
- Amitriptyline
- Nortryptyline
- Trimipromine
- Imipromine
- Doxepin
- Protryptyline
- Clomipramine
146
Side effects of TCA
- Adrenergic over stimulation
- Serotonin syndrome
- Postural hypotension
- Weight gain
- Sedation
- Atropine like side effects
- **Antimuscaranic effect**
147
Long acting TCAs
- Amitriptyline
- Imipromine
148
Which TCA is used in nocturnal enuresis
Imipromine
149
Early warning symptoms of serotonin syndrome
Throbbing headache
- Tremor, tachycardia, shivering, mania
150
TCA used in neuropathic pain
Amitriptyline
Nortryptyline
151
What antidepressant is safe for use in unstable angina or MI
Sertraline
152
How long is the wash out period for antidepressants before starting MAOI
- **2 weeks** with MAOI
- **1-2 weeks** with Tricyclic
*(3 weeks if starting **clomipramine or imipramine**)*
- **1 week** with SSRI
*(5 weeks with **fluoxetine** and 2 weeks with **sertraline**)*
153
Which antidepressants doesn’t require washout period
Moclobamide
154
What antiemetic is used in nausea and vomiting caused by Parkinson’s drug
Domperidone
155
What benzodiazepine is used in alcohol withdrawal syndrome
Chlordiazepoxide hydrochloride
Diazepam
156
What are TCA related drugs
- Mianserin
- Trazodone
157
Examples of SSRIs
- Fluoxetine
- citalopram
- paroxeline
- sertraline
- escitalopram
158
Which SSRI has a long half life
Fluoxetine
159
Which SSRIs cause QT prolongation
- Citalopram
- escitalopram
160
Which SSRI has a great risk of withdrawal
Paroxetine
161
Which SSRI is safe after MI or unstable angina
Sertraline
162
Which SSRI is licensed in children below 18
Fluoxetine
163
Side effects of SSRI
- Insomnia
- impotence
- Bruxism (grinding of teeth)
- **hyponaetramia**
- **suicidal thoughts** - MHRA
- **increased bleeding risk** - interacts with warfarin, NSAIDs, DOACs
164
Example of SNRIs
- Venlafaxine
- duloxetine
165
Which SNRI is used in diabetic neuropathy?
*when diabetes cause damage to nerves*
Duloxetine
166
Example of NDRI
Bupropion
167
Which antidepressant can be used in smoking cessation
Buproprion
168
Side effect of NDRI
Can precipitate seizures
169
Autoreceptor inhibitors and their side effects
(TCA related drugs)
- **Trazodone** - hypotension
- **mianserin** - seizure
- **mirtazapine** - sedation, weight gain, blood dyscrasias
170
Examples of MAOi
- **Meclobemide** (selective - short acting, no cheese reaction)
- **phenalzapine** (non selective - cheese reaction)
171
What two antidepressant classes are fatal when given together
TCA + MAOIs
172
Treatment pathway for depression
1. **SSRI** - first line
2. Increase SSRI dose or different SSRI
3. Swap to mirtazapine or SNRI
4. Reversible MAOI
173
Duration of treatment with antidepressants
- Takes at least 2 weeks to show effect
- May feel worse initially
- Wait **4 weeks (6 in elderly)** to see if effective
- Continue for atleast **6 months (12 in elderly)**
- **2 years in recurrent depression**
174
What is used to treat cheese reaction
IV phentolamine
175
Monitoring requirements for antipsychotics
- **Full blood count, urea and electrolytes and liver** ( start, yearly)
- **blood lipids and weight** (baseline, 3 months, yearly)
- **fasting blood glucose** (baseline, 4-6 months, yearly)
- **blood pressure** (before, dose titration)
- **prolactin** (start, 6 months, yearly)
176
Which antipsychotics doesn't have prolactin side effects
Aripiprazole
*(production of breast milk or breast in men)*
177
What are the extrapyramidal symptoms
- Parkinsonism
- dystopia ( abnormal face and body movement)
- dyskinesia (more common in children)
- akathisia (inner restlessness)
- tardive dyskinesia (rhythmic involuntary movement of tongue, face and jaw)
**STOP at first sign of fine vermicular movements of tongue**
178
Other drugs that interact with antipsychotics to increase EPSEs
- Metoclopramide
- levodopa
179
Drugs that increase risk of CNS depression with antipsychotics
- Hypnotics
- benzodiazepines
- opioids
- antiepileptics
180
Drugs that increase risk of hypotension with antipsychotics
- Antihypertensive's
- diuretics
- nitrates
181
Examples of first generation antipsychotics
- Haloperidol
- chlorpromazine, theoridarines, fluphenazine
- thiothixene
- pimozide
- loxapine
182
Effect of first generation antipsychotics
- increase risk of Parkinson's (EPSE)
- increase negative symptoms (depression)
- decrease manic symptoms
- increase in prolactin (sexual dysfunction)
183
What first generation antipsychotics have highest risk of cardiovascular risk (QT prolongation)
Pimozide
Haloperidol
184
What is used to treat or prevent EPSEs
Procyclidine
185
Which first gen antipsychotic has low potency
Chlorpromazine
*the others have high potency: stronger antipsychotic effect and more EPSE*
186
Patient counselling with chlorpromazine
Avoid direct contact with tablets
Tablets should not be crushed and solutions should be handled with care
187
Which antipsychotic should not be taken at night
Flupentixol
188
Which antipsychotic causes bronchospasm
Loxapine
189
Examples of second gen antipsychotics
- Aripiprazole
- clozapine
- lurasidone
- olanzapine
- quetiapine
- risperidone
- ziprasidone
190
Which second gen antipsychotic has highest potential to cause EPSE and prolactinemia
Risperidone
191
Second gen antipsychotics with strong affinity for serotonin receptors
‘**C**i**ROQ**’
- **C**lozapine
- **R**isperidone
- **O**lanzapine
- **Q**uetiapine
*Metabolic side effects: weight gain, hyperglycaemia, dislipidemia*
192
Which second gen antipsychotics have the most sedative effects
Clozapine
Olanzapine
Quetiapine
193
What second gen cause postural hypotension and temp regulation
Clozapine
Risperidone
Quetiapine
194
Which second gen cause agranulocytosis and requires regular blood count monitoring
Clozapine
*report signs of infection*
195
Which second gen causes constipation
Clozapine
196
Which antipsychotic is most effective in resistant schizophrenia
Clozapine
197
Which antipsychotics is sexual dysfunction most common with
- Haloperidol
- risperidone
198
Which second gen antipsychotic causes CNS and respiratory depression
Olanzapine
199
1. How long should clozapine be given to assess effectiveness
2. What happens if patient misses more than 2 doses
3. How should clozapine be withdrawn
1. At least **8-10 weeks**
2. Reinitiate
3. Reduce dose over **1-2 weeks**
200
Drugs that interact with clozapine
- Aminosalicylates
- immunosuppressants (eg. Methotrexate)
- cytoxic drugs
201
When to discontinue clozapine
Myocarditis
Cardiomyopathy
202
Side effects of clozapine
- Constipation
- agranulocytosis
- risk of fatal myocarditis and cardiomyopathy
- hypersalivation
- postural hypotension
- sedation, weight gain
- hyperglycaemia
- dislipidemia
203
What is used to treat hypersalivation caused by clozapine
Hyoscine
204
Monitoring requirements with clozapine
- Full blood count → weekly for 18 weeks, then every 2 weeks for a year, monthly onward
- physical examination and full med history before starting
- report constipation before taking next dose
- blood glucose
- lipid concentration
205
Drugs used in Parkinson's
*aim to increase dopamine activity*
- levodopa
- selegiline / rasagiline
- tolcapone
- bromocriptine, ropinirole, pramipexole, rotigotine, apomorphine
- antimuscaranic agents (procyclicline,biperiden)
- amentadine
206
Which antiemetic is used in Parkinson's
Domperidone
*doesn’t cross bbb*
207
Side effects of levodopa
• **Impulse control disorders**
• **Sudden onset of sleep**
- Nausea, loss of appetite - give domperidone
- hypotension
- mental disturbances
- red urine, sweat and saliva
208
Side effect of selegiline and rasagiline
- Nausea
- Insomnia
- dyskinesia
- **visual hallucinations**
Selegiline: cheese reaction
209
Side effects of entacapone and tolcapone
- Disacoloration of body fluids
Tolcapone: severe diarrhoea and liver toxicity
210
Side effect of dopamine agonists
*Rotigotine, pramipexole*
- Nausea
- postural hypotension
- mental disturbance
- **day time sleepliness**
211
Side effect of bromocriptine
Pulmonary and cardiac fibrosis
212
Treatment pathway for Parkinson's
1. **Levodopa** - pts whose motor symptoms reduce quality of life
2. **Pramipexole, ropinirole, rotigotine** - enhanced side effects (non-ergot)
3. Selegiline, rasagiline
4. Entalcopone, tolcapone
5. If not we’ll managed then bromo and carbeh
- Amantadine if dyskinesia not adequately managed
- apomorphine SC in 'Off' episodes *(start domperidone 2 days before to stop nausea and vomiting)*
213
Risk of using apomorphine for too long in Parkinson's
QT prolongation
214
What colour does entacappone make urine
Reddish-brown
215
When are entacapone and tolcapone used
With levodopa in 'end of life' motor flunctuation
216
What is used in nausea and vomiting related to motion sickness or morning sickness?
Antihistamines
Eg. Promethazine
*side effect: drowsiness and sedation*
217
What antiemetic is good for chemo patients, radiation and post surgery
- 5-ht 3 receptor antagonist *’setron’*
Eg. **ondasetron**
*side effect: headache and GI upset*
- **doperidol**
218
What is used in pregnancy for bad nausea and vomiting
- when should it be avoided
Ondasetron
- avoid in 1st trimester
219
How long should metaclopromide be used?
Only for 5 days
- good in chemo and patients with reflux and hepatobile
- Side effect: EPSE and GI disturbance
220
What antiemetic is used in prophylaxis and motion sickness
- which is preferred if sedative effect is desired
Muscurinic receptor antagonist
Eg. **Hyoscine**
- sedative: **cyclizine or cinnarizine**
- antimuscurinic side effects
221
What is used to treat nausea and vomiting in pregnancy
- **Promethazine**
- prochorperazine
- metoclopramide
222
Side effect of domperidone
Increased risk of serious cardiac side effects
223
Duration of treatment with domperidone
- dose adult / children
Do not exceed 1 week
- adult (>12 years,>35 kg) → **10mg TDS**
- children (<12 years, <35 kg) → **250 mcg/kg TDS**
224
How long does chronic pain last?
>12 weeks
225
What is noceceptive pain?
Caused by damage to the nerves
- burning, prickling, pins and needles, shooting or stabbing sensation
- eg. Musculoskeletal pain, dental pain, moderate- severe pain, period pain
226
What is used in musculoskeletal pain
NSAIDs including aspirin
227
What is used in dental pain
NSAIDs temporarily (1-7 days)
- ibuprofen, diclofenac, aspirin
If associated with acute problems of the oral mucosa
- benzydamine hydrochloride mouthwash or spray
228
What is used in period pain
- Oral contraceptives
- antispasmodics (peppermint oil, hyoscine butylbromide)
- **NSAIDs** more useful
229
What is used in neuropathic pain
- TCA (amnitriptyline, nortryptiline)
- gabapentin and pregablin (risk of suicidal thoughts)
230
What is used in visceral pain
Opioids
*trunk, heart, abdominal and pelvic organs *
231
What is used to treat swelling caused by pressure from tumors
Dexamethasone
232
What should be avoided in sickle cell
**Pethidine** → can cause seizures
233
What is used to treat paracetamol overdose
Acetylcysteine
234
Aspirin dose in severe and pain
300 - 900 mcg, 4-6 hours, PRN
- take with food
- CI under 16
235
Dose of ibuprofen for child 2-3 months in post-immunisation pyrexia
50 mg STAT
Repeat after 6 hours if necessary
236
Which opined can be used in nociceptive and neuropathic pain
Methadone
237
Side effects of opioids
**’MORPHINE’**
- Miosis (pin point pupils), muscle rigidity
- Out of it (sedation)
- Respiratory depression
- Postural hypotension
- Hyperalgesia, hallucination
- Infrequency (urinary retention, constipation)
- Nausea and vomiting
- Euphoria
238
Side effect specific to morphine and meperidine
Hypotension
*provoke release of histamines*
Meperidine → tachycardia
239
When are opioids contraindicated
- **Coma patients** → CNS depression
- **IBD** → reduces GI motility
- **Respiratory disease** → respiratory depression
- head injury or raised intracranial pressure
- increased sedation
- **MAOIs** → hypertension/ hypotension
240
When is codeine contraindicated
- Children < 12 years
- ultra rapid CYP2D6 metabolisers
- breast feeding mothers
- <18 years with surgery for tonsils or adenoids for sleep apnoea
241
Counselling and advice with fentanyl
- Avoid exposing application site to external heat
- monitor for up to 24 hours after patch removal for patients with severe side effects
- patches should be removed immediately in case of breathing difficulties, marked drowsiness, confusion, dizziness or impaired speech.
- **For patches, apply to dry, non-irritated, non-irradiated, non-hairy skin on torso or upper arm, removing after 72 hours and siting replacement patch on a different area (avoid using the same area for several days).**
242
What is used to treat migraine
1. Acute: aspirin, paracetamol or NSAIDs
2. If analgesics are in adequeate; 'triptans'
3. Ergotamine → stop if numbness or tingling of extremities
243
What is used in prophylaxis of migraine
**Pizotifen**
**Propanol** → associated with cardiovascular events
244
What is used in opioid toxicity
Naloxone
245
When is tramadol contraindicated
- Hypothyroidism
- epilepsy
246
What side effects do Carbamezapine, phenytoin and valporate have in common
- hepatic impairment
- hypersensitivity
- behaviour + suicidal
- blood dyscrasia
- Vit D deficiency
247
Carbamazepine electrolyte imbalance
Hyponatraemia
248
Lamotrigine side effect
Steven Johnson syndrome
249
Therapeutic range for carbamazepine and phenytoin
Carbamazepine - **4-12**
Phenytoin - **10-20**
250
What to give for sudden onset of sleep
Modafinil
251
If Parkinson’s pt gets hypotension
Midodrine
252
MAO-B OTC interaction
NO pseudoephedine/ phenylephedine
**hypertensive crisis**
*Selegiline, rasagiline*
253
Which antipsychotics cause the most weight gain
**CO**w
- clozapine
- olanzapine
254
Which antipsychotic is given to fix sexual dysfunction
Aripirazole
255
Acute anxiety tx
Benzodiazepines - 14 days
Busiprone
256
Maintenance of anxiety
SSRI
257
Which antidepressant can be given to under 17
Fluoxetine
258
Which antidepressant is safe in cardiac event
Sertraline
259
What age can codeine be taken OTC
12
18 - if associated to linctus
260
Increase of morphine per day in palliative care
1/3 to 1/2 increase per day
261
Which drug is not in the initial plan for Parkinson’s
Entacapone
Talcapone
262
Which SSRI has sedative effect
Mirtazapine
263
What pain drug should be avoided in sickl cell
Pechidine
264
What is used in dental pain
NSAIDs temporarily (1-7 days)
- ibuprofen, diclofenac, aspirin
If associated with acute problems of the oral mucosa
- benzydamine hydrochloride mouthwash or spray
