CNS 3

Question 1

What is the first line tx for ADHD

Answer 1

Methylphenidate or Lisdexamphetamine

Question 2

State what drug to offer patients that cannot use Methylphenidate or Lisdex

Answer 2

Atomoxetine

Question 3

State when atomoxetine may be used as first line tx?

Answer 3

For drug misuse patients

Question 4

What are methylphenidate counselling advice

Answer 4

Affects driving, effects increased by alcohol

Question 5

Patient and carer advise for atomoxetine

Answer 5

Monitor for agitation, irritability, suicidal thoughts, self harming, unusual changes in initial months of tx or after dose change
Hepatic impairment

Question 6

Monitoring for atomoxetine, methylphenidate

Answer 6

Monitor for appearance or worsening of anxiety, depression or tics.

Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.

Question 7

What is bipolar Disorder?

Answer 7

Serious chronic condition where there is a period of depression and periods of Mania or hypomania

Question 8

Symptoms of mania

Answer 8

Patients with Mania will have 3 or 4 of the following
Grand ideas about self
Increase energy or less sleep
More talkative than usual
Full of new ideas and plans, unreliastic plan
Irritation or agitation
Want to do lots of pleasurable things

Question 9

Medication use to manage bipolar

Answer 9

Bz
Antisychotics
Carbamezepine
Valproate
Lithium

Question 10

Facts about Mania and hypomania drugs

Answer 10

They are used to control acute attacks and to prevent recurrent episodes of Mania or hypomania

Question 11

Duration of tx for bipolar

Answer 11

Continue long term tx of bipolar for atleast 2 years from the last manic episode and up to five years if patient has a risk factor for relapse

Question 12

When to give Antidepressants in bipolar patients

Answer 12

Give it for depression

Question 13

Antidepressants in bipolar should be avoided in the following conditions

Answer 13

Rapid cycling bipolar disorder
Recent hx of hypomania
Rapid mood fluctuations

Question 14

When is Bz used in bipolar disorder?

Answer 14

Eg Lorazepam
For agitation or behavioural disturbance
Avoid long term use as it may cause dependence

Question 15

State examples of antipsychotics used to treat mania and hypomania

Answer 15

Olanzepine, Quetiapine or risperidone

Question 16

State what other drug to add to Antisychotics if response is inadequate

Answer 16

Add Lithium or valproate

Question 17

Facts about discontinuing Antipsychotics

Answer 17

Reduce it gradually over 4weeks if pt is continuing with other anti manic drugs

Question 18

Do you give Antidepressants in mania or hypomania?

Answer 18

No

Question 19

Reduce the dose of antipsychotics over how long if pt is stopping anti manic drugs or if there is a hx of relapse in mania

Answer 19

3 months

Question 20

What’s the indication of Carbamezepine

Answer 20

For prophylaxis of bipolar disorder (manic depressive disorder)
Use in pt with rapid cycling manic depressive illness (4 or More effective episodes/year

Question 21

State the indication of valproate

Answer 21

It is used to tx and prophylaxis of manic episodes of bipolar

Question 22

Indication of Lithium salt

Answer 22

Used in prophylaxis for and tx of mania , hypomania and depression in bipolar disorder

Question 23

The two forms of Lithium have different bioavailabilty. True or false?

Answer 23

True
Eg lithium citrate and carbonate

Question 24

When does full prophylactic effect of Lithium occur after initiation of therapy?

Answer 24

6-12 months

Question 25

List some Contraindications with Lithium

Answer 25

Dehydration Low sodium diets (Increase lithium conc) Untreated hypothyroidism (lithium affects T4 production sodium can cause hypothyroidism) Significant renal impairment Cardiac disease Addison's disease

Question 26

What are the cautions with Lithium

Answer 26

Avoid abrupt withdrawal Diuretic tx (increases risk of toxicity) eg loops, ace inhibitors QT interval elongation Review dose in Diarrhoea, elderly, vomiting, surgery and intercurrent infection) LTM use has been associated with thyroid disorders and mild cognitive and memory impairment

Question 27

Monitoring in lithium for long term use

Answer 27

Monitor Thyroid function every 6months Assess need for continuity regularly and maintain patients after 3-5 years on lithium only if benefits persists

Question 28

Side effects of Lithium

Answer 28

Arrhythmia Lowers seizure threshold Tremor QT interval elongation Electrolytes imbalance Renal dysfunction(polydipsia, polyuria) Skin reactions Vision disorder Cardiomyopathy and AV block GI disturbance Drowsiness, unsteadiness and confusion fatigue hair loss and weight gain Intracranial HTN Leukocytes Movement disorders

Question 29

Signs of Lithium OD

Answer 29

GI ( Nausea and Vomiting) Visual disturbance Polyuria, muscle weakness Fine tremor CNS disturbance Cardiac Arrhythmia AV block Renal failure Seizure Coma and death

Question 30

What's the mnemonic for lithium side effects?

Answer 30

LITHIUMS Levels Increased urination Thirst, tremor and teratogenicity Hypothyroidism Interaction ( NSaids, ARBS/ DIURETICSS/ ANTACIDS UPSET STOMACH MUSCLE WEAKNESS SKIN EFFECTS ( ACNE, PSORIASIS)

Question 31

Is lithium safe in Breastfeeding?

Answer 31

Avoid, present in milk and risk of toxicity in infants

Question 32

What stage of pregnancy should lithium be avoided?

Answer 32

First trimester ( risk of teratogenicity including cardiac abnormality)

Question 33

Lithium dose is increased during what stage of pregnancy ?

Answer 33

2nd and 3rd trimester but on delivery, return abruptly to normal

Question 34

State what monitoring is required for pregnant pt on lithium

Answer 34

Monitor serum concentration closely during pregnancy as there is risk of toxicity in neonates

Question 35

What is the therapeutic range of Lithium

Answer 35

0.6-0.8mmol/L( those prescribed lithium for the first time) 0.8-1 mmol/L( mania and pt who previously relapsed Elderly: 0.4-0.6mmol/L pt aged 65 and over

Question 36

Monitoring requirements for Lithium

Answer 36

Take blood samples every 12 hours after dose initiation Weekly routine serum- lithium conc after initiation and every 3months/year and every 6months thereafter when dose is stable

Question 37

State what to assess before initiation of Lithium

Answer 37

Cardiac, thyroid, renal function, BMI, FBC and electrolytes

Question 38

Lithium tx cessation

Answer 38

Abrupt discontinuation increase risk of relapse Reduce gradually over a period of about 4weeks - 3months In lithium discontinuation abruptly, consider changing therapy to an atypical antipsychotics or valproate

Question 39

What is the pt and carer advice for lithium

Answer 39

Report signs and symptoms of Lithium toxicity Renal dysfunction Hypothyroidism- weight gain Maintain adequate fluid intake Avoid dietary changes which reduce or increase sodium intake Give tx pack Persistent headache and visual disturbance Maintain same brand of Lithium

Question 40

Which drug increases lithium concentration

Answer 40

Something that reduces sodium will increase Lithium Ace Inhibit/ARBs Diuretics/ loop/thiazide NSAIDs Metronidazole Amiodarone Tetracycline

Question 41

State mnemonic for drugs that increase Lithium conc

Answer 41

LAND on the MAT

Question 42

Which drugs decreases lithium conc

Answer 42

Sodium containing antacids and soluble/effervescent analgesics(high salt) Urinary alkalinizing agents for cystitis Theophylline Osmotic and carbonic anhydrase inhibitor diuretics

Question 43

Drugs which increase neurotoxicity with lithium

Answer 43

Carbamezepine Antipsychotics SsRs Tristan CCB eg verapemil Drugs that cause hypokaelamia prolonged QT interval with Lithium eg diuretic, corticosteroids, B agonist.

Question 44

Drugs which increase serotonin syndrome with lithium

Answer 44

Citalopram Monoamine oxidase inhibitors Tramadol St John's wort Sumatriptans