CNS

Question 1

carbamazepine

Answer 1

use-dependent Na-block;
often first line (generalised)

SEs: rash, dizzy, double vision, blood disorders, autoinduction/interaction, birth defects

Question 2

sodium valproate

Answer 2

^GABA + sodium blockage; f
irst line (Generalised), second line (absence)

SEs: weight gain, tremor, sedation, TFTs, leucopenia, thrombocytopenia; birth defects, liver damage

Question 3

phenytoin

Answer 3

sodium channels; zero-order (variable response ) and narrow TI; rarely used
good for acute (i.e. stop fits)

SEs: gum growth, nystagmus, BG (rare); birth defects

Question 4

lamotragine

Answer 4

sodium channels and decreased glutamate; non-sedating; 
first line (generalised, pregnancy), second line (absence)

SEs: blood and skin disorders, BM toxicity (warn about ‘flu’ and/or rash);

Question 5

BZD

Answer 5

bind subunits of GABA receptors on Cl channels » increased GABA;
good for status;

SEs: skill and motor; low tolerance and dependence;

Question 6

Anti-epileptic precautions

Answer 6

preggo: teratogens; lowest dose possible for shortest time (prevention better than seizures)
- first = all or nothing (14d) and organ development issues (10w); greatest risk
- second = CNS (NTD with C, V, P) and general growth
- third = more predictable; post-birth effects; give folate and vitamin K (T3)

• liver enzyme inducers » interactions e.g. affect warfarin (Decreased activity)
• monitor: LFTs, INR (C, V), FBC (aplastic anaemia (L), Tpenia (V)

Question 7

SSRI

Answer 7

5HT; first lines (tolerance and safety in OD);
morning dose;

bleeding risk, epilepsy caution, interactions

Question 8

TCA

Answer 8

NA and 5HT (also mACh-R and histamine); antimuscarinic SEs, sedating (night dose); also used in neuropathic pain, migraine, IBS

SEs: dry mouth, sedation, blurred vision, constipation, urinary retention; OD risk

Question 9

NARI (reboxetine)

Answer 9

selective; used if SSRI-resistant and unable to take TCA

Question 10

SNRI (venlafaxine)

Answer 10

5HT and NA; non-sedating + no antimusc effect but withdrawal risk;

caution DM/IHD
SEs: hypertension, GI

Question 11

NaSSAs (mirtazepine)

Answer 11

NA and 5HT; limited antimusc effect, but weight gain and sedation

Question 12

MAOI

Answer 12

block breakdown (NA, 5HT, Dopamine);

diet and drug interactions (cheese reaction and Hypertensive crisis - catecholamines)

Question 13

Management of depression

Answer 13

if mild, watch and wait (2/52); CBT; not pharma to start
other non-pharma: sleep hygiene and ECT

if started on pharma: first-line SSRI (TCA if sleep issues)
review after 2 wk: poor response = increase/switch
review 2-4w for 3m, then less regularly if good response
remission >6m (2y if 2 episodes) » ?Withdrawal (gradual dose/freq, approx 4w); dizzy, flue, dd and nausea, paraesthesia, anxiety, headache

Question 14

Management of epilepsy

Answer 14

TONIC-CLONIC: carbamazepine, lamotrigine, sodium valproate

ABSENCE: ethosuximide; sodium valproate, lamotrigine second line

MYOCLONIC: sodium valproate, clonazepam, levetiracetam

ATYPICAL ABSENCE/ATONIC/TONIC: sodium valproate, lamotrigine, clonazepam

MONITOR: blood (leucopenia), liver, skin

Question 15

management of anxiety

Answer 15

BB: SANS SEs; symptom relief

BZD: ^GABA; decreased anxiety and aggression, increased sleep;

AD: many help in panic attacks (anxiolytics); better long-term

buspirone: 5HT (and DA) activation; 2-3w delay, no sedation, no panic help; dizzy, nausea, headach

Question 16

management of bipolar

Answer 16

Lithium: acute treatment and prophylaxis; ^5HT? Modulate glutamate?
-avoid in renal impairment; narrow TI, interactions

Neuroleptics: antipsychotics; control symptoms; suppress/control DA; used in manic phase

Anticonvulsants: 2nd line mood stabilisers; PPx; C and V

Question 17

status epilepticus

Answer 17

1st line: IV lorazepam; buccal midazolam (if no IV; less effective in longer fits); IV diazepam (if Lor not available)

2nd line: IV phenytoin (20mg/kg, rate important -arrest risk; give over 20-30m), IV phenobarbitol or propafol; rectal diazepam 10-20mg community