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BNF Chapters > CNS > Flashcards

CNS Flashcards

1
Q

Treating (attenuating) alcohol withdrawal symptoms

A

Long acting benzodiazepine (e.g. Chlordiazepoxide/diazepam), carbamazepine or clomethiazole (inpatient only)

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2
Q

How to treat alcohol withdrawal seizures

A

Fast acting benzodiazepine e.g. Lorazepam

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3
Q

What is delirium tremens characterised by

A

Agitation, confusion, paranoia and visual and auditory hallucinations

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4
Q

Treating alcohol dependence

A

Psychological intervention, acamprosate, oral naltrexone

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5
Q

Wernickes treatment

A

Parenteral and then oral thiamine

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6
Q

Dental anaesthetics

A

Lidocaine, mepivicaine (can be used without adrenalin in patients with heat problems), prilocaine

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7
Q

Why are neuromuscular blocking drugs used

A

To provide relaxation and prevent reflex muscle movements (facilitating tracheal intubation)

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8
Q

Propofol characteristics

A

Rapid recovery, less hangover effect

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9
Q

Nitrous oxide use

A

Maintaining anaesthesia for analgesia

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10
Q

NO and air pressure

A

Increased pressure in closed spaces so dangerous in patients with no pneumothorax, intracranial air, underwater dive, intraocular injection

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11
Q

Treating musculoskeletal pain

A

Non-opioid, paracetamol, aspirin, NSAIDS

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12
Q

Visceral pain treatment

A

opioids

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13
Q

Pain medication to avoid in sickle cell crisis

A

Pethidine, as accumulation of a neurotoxic metabolite can precipitate seizures

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14
Q

Oral mucosal pain

A

Benzydamine hydrochloride mouthwash or spray until cause dealt with

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15
Q

General dental pain relief treatment

A

NSAIDS (paracetamol for antipyretic effect)

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16
Q

Dental pain and opioids

A

Opioids are relatively ineffective

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17
Q

Dysmenorrhoea treatment

A

Paracetamol, NSAID, antiemetic if needed, antispasmodics (alverine citrate)

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18
Q

Naproxen Dysmenorrhoea/MSK Pain regimen

A

Initially 500 mg, then 250 mg every 6–8 hours as required, maximum dose after the first day 1.25 g daily.

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19
Q

Aspirin pain indications

A

Headache, transient musculoskeletal pain, dysmenorrhoea, and pyrexia

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20
Q

Pros and cons of enteric aspirin

A

Slow onset, so unsuitable for single dose analgesic use but prolonged action may be useful for night pain, less gastric irritation

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21
Q

Nefopam indication and regumen

A

Initially 60 mg(30mg in elderly) 3 times a day, adjusted according to response; usual dose 30–90 mg 3 times a day. Moderate pain.

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22
Q

Issue with caffeine in analgesic preparations

A

Withdrawal may result in headache

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23
Q

Morphine contraindications

A

raised intracranial pressure, respiratory depression, head injury,

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24
Q

Morphine side effects

A

appetite decreased; asthenic conditions; gastrointestinal discomfort; insomnia; neuromuscular dysfunction

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25
Q

Buprenorphine unique attribute

A

Opioid agonist and antagonist, naloxone only partially reverses

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26
Q

Buprenorphine relative to morphine

A

Longer duration, sublingually 6-8 hours

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27
Q

Why is diamorphine used in palliative care

A

Less nausea and hypotension, greater solubility so smaller volumes required in emaciated patients

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28
Q

Methadone vs morphine

A

Less sedating, longer duration

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29
Q

Oxycodone vs morphine

A

Similar so used second line

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30
Q

Pethidine vs morphine

A

Short acting, less constipating, less potent, used in labour but morphine preferred for obstetric pain

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31
Q

Tapentadol MOA (vs morphine)

A

Inhibits noradrenaline and opioid agonist, has less NV, constipation

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32
Q

Tramadol MOA

A

Opioid and serotonergic and adrenergic pathways inhibitor

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33
Q

When is codeine used

A

When paracetamol and ibuprofen are ineffective

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34
Q

Codeine vs dihydrocodeine

A

Similar, high doses of dihydro may provide more pain relief but more nausea and vomiting too

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35
Q

Meptazinol indication

A

Moderate to severe pain

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36
Q

When are antidepressants used

A

Moderate to severe depression (mild depression but history of moderate/severe depression)

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37
Q

Different Antidepressant classes

A

MAOI, SSRI, TCA

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38
Q

Why/when is electroconvulsive treatment required in severe depression

A

There may be a 2 week interval before antidepressant action takes place, the delay may be hazardous or intolerable

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39
Q

What may occur during first few weeks of treatment

A

Increased potential for agitation, anxiety and suicidal ideation

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40
Q

SSRI vs other antidepressants

A

Safer in overdose than others, sertraline can be used in unstable angina/recent MI, are less sedating and have less antimuscarinic and cardiotoxic effects than TCA

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41
Q

TCA vs other antidepressants

A

Similar efficacy to SSRIs, more side effects leading to discontinuation and toxicity in overdose is problematic

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42
Q

Antidepressant monitoring at initiation frequency

A

Review every 1-2 weeks at the start

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43
Q

How long should antidepressants be used for before considering a switch

A

At least 4 weeks (6 weeks in elderly) ( if there is a partial response continue for further 2-4 weeks)

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44
Q

What to do for patients following remission

A

Antidepressant treatment continued at same dose for at least 6 months (12 in elderly or receiving treatment for GAD)

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45
Q

What to do for patients with history of recurrent depression

A

Maintenance treatment for at least 2 years

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46
Q

Common side effect amongst antidepressants

A

Hyponatraemia (particularly elderly potentially due to secretion of antidiuretic hormone)

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47
Q

What class if antidepressants is hyponatraemia most common in

A

SSRIs

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48
Q

When to consider hyponatremia in those taking antidepressants

A

Drowsiness, confusion, convulsions

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49
Q

Serotonin syndrome cause

A

excessive central and peripheral serotonergic activity

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50
Q

When does serotonin syndrome occur

A

Hours/days following initiation/dose escalation/overdose of serotonergic drug or replacement without a washout particularly when the first drug is irreversible MOAI/long half life

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51
Q

Symptoms of serotonin syndrome

A

Neuromuscular hyperactivity, autonomic dysfunction, altered mental state

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52
Q

Altered mental state

A

Agitation, confusion, mania

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53
Q

Autonomic dysfunction

A

Tachycardia, blood pressure, hyperthermia, diaphoresis, shivering, diarrhoea

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54
Q

Neuromuscular hyperactivity

A

Tremor, hyperreflexia, clonus, myoclonus, rigidity

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55
Q

Treating serotonin syndrome

A

Withdrawal of serotonergic medication, supportive care and specialist advice

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56
Q

What to do if failure to respond to SSRI

A

Increase SSRI dose or switch to different SSRI/mirtazapine

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57
Q

Second line antidepressant treatment

A

Mirtazapine, lofepramine, moclobemide, reboxetine

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58
Q

Mirtazapine class

A

presynaptic alpha2-adrenoreceptor antagonist which increases central noradrenergic and serotonergic neurotransmission.

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59
Q

Venlafaxine class

A

A serotonin and noradrenaline re-uptake inhibitor.

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60
Q

Lofepramine class

A

TCA

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61
Q

Moclobemide class

A

MAOi

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62
Q

When is venlafaxine used

A

Severe depression

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63
Q

What to do if failure to respond to second line antidepressant

A

Different antidepressant class used, augmenting agent e.g. Lithium, aripiprazole, olanzapine, quetiapine, risperidone (all except lithium unlicensed) or electroconvulsive therapy

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64
Q

Managing acute anxiety

A

Benzodiazepine or buspirone

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65
Q

Chronic anxiety length

A

More than 4 weeks

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66
Q

Treating chronic anxiety

A

Antidepressant

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67
Q

How to overcome antidepressant not working initially when treating anxiety

A

Benzodiazepine given

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68
Q

How to treat GAD

A

Psychological treatment before initiating an antidepressant

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69
Q

Antidepressants used in anxiety

A

SSRI e.g. Escitalopram, paroxetine, sertraline (unlicensed), SNRI e.g. Duloxetine and venlafaxine , pregabalin if both classes fail

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70
Q

Treating Panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder a

A

SSRIs first line. Second line: clomipramine (ocd/panic) moclobemide (sad) imipamine (panic)

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71
Q

TCA MOA

A

Block the re-uptake of both serotonin and noradrenaline, although to different extents

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72
Q

TCAs with sedative properties

A

Amitriptyline hydrochloride, clomipramine hydrochloride, dosulepin hydrochloride, doxepin, mianserin hydrochloride, trazodone hydrochloride, and trimipramine.

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73
Q

TCAs with less sedative properties

A

Imipramine hydrochloride, lofepramine, and nortriptyline.

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74
Q

What TCA type to use for agitated anxious patients

A

Sedative

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75
Q

What percent of patients does TCA not work on

A

10-20% so use sufficiently high dose

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76
Q

MAOi and interaction avoidance

A

Other antidepressant should not be started 2 weeks after treatment with MAOis (3 weeks for clomipramine or imipramine)

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77
Q

When can you start MAOi after another MAOi

A

at least 2 weeks after a previous MAOI has been stopped (then started at a reduced dose)

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78
Q

When can you start MAOi after TCA

A

at least 7–14 days after a tricyclic or related antidepressant (3 weeks in the case of clomipramine or imipramine) stopped

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79
Q

When can you start MAOi after SSRI

A

at least a week after an SSRI or related antidepressant (at least 5 weeks in the case of fluoxetine) has been stopped

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80
Q

Who responds best to MAOi

A

Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features

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81
Q

TCA and the elderly

A

STOPP in those with dementia, narrow angle glaucoma, cardiac abnormalities, urinary retention history, prostatim, and if first ;ine

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82
Q

Isocarboxazid and phenelzine risk

A

Hepatotoxicity (all MAOi)

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83
Q

MAOi monitoring

A

Blood pressure

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84
Q

MAOi counselling points

A

Patients should be advised to eat only fresh foods and avoid food that is suspected of being stale or ‘going off’. This is especially important with meat, fish, poultry or offal; game should be avoided.

Avoid alcohol

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85
Q

Tyramine-rich food

A

Mature cheese, salami, pickled herring, Bovril®, Oxo®, Marmite® or any similar meat or yeast extract or fermented soya bean extract, and some beers, lagers or wines

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86
Q

Foods containing dopa

A

Broad bean pods

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87
Q

Contributions to hypertensive symptoms when on MAOi

A

Tyramine rich foods and dopa containing foods

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88
Q

ADHD characteristics

A

Hyperactivity, impulsivity, inattention leading to social/educational/occupational difficulties

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89
Q

Non-drug ADHD treatment

A

Balanced diet, good nutrition, regular exercise, environmental modifications, lighting , noise, reducing distraction, shorter periods of focus with movement breaks

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90
Q

ADHD first line

A

Lisdexamfetamine, methylphenidate 6-week trial

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91
Q

When is dexamfetamine used in ADHD

A

If the patient has a beneficial response from lisdexamfetamine but can’t tolerate longer duration

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92
Q

Why is MR ADHD treatment used

A

Pharmacokinetic profile, convenience, improved adherence, reduced risk of drug diversion, no need to take at work

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93
Q

Drugs that shouldn’t be generally stopped before surgery

A

Antiepileptics, antiparkinsonian drugs, antipsychotics, anxiolytics, bronchodilators, cardiovascular drugs, glaucoma, immunosuppreants, thyroid/antithyroid

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94
Q

When should lithium be stopped before a surgery

A

24 hours before if major, can continue if minor

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95
Q

ACE/ARB and surgery

A

Severe hypotension after anaesthesia so discontinue 24 hours before surgery

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96
Q

Anaesthesia and corticosteroids

A

Anaethesists should be informed of corticosteroid use including inhalers because blood pressure may drop if there is no corticosteroid during anaesthesia

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97
Q

When should potassium sparing diuretics be stopped before surgery

A

The morning due to hyperkalaemia arising from renal impairment

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98
Q

Substitution therapy missed doses repercussions

A

Missing 3 days = reduce dose due to overdose risk, missing 5 days = restart, especially buprenorphine

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99
Q

Why is buprenorphine preferred to methadone

A

Less sedating, interactions, easier dose reductions, lower overdose risk, alternate days at higher doses, shorter drug-free period before naltrexone induction to prevent relapse, titrate more rapidly

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100
Q

When does buprenorphine precipitated withdrawal occur

A

Other opioid agonists in circulation , occurs 1-3 hours within first buprenorphine dose

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101
Q

What is given when symptoms of precipitated withdrawal are severe

A

Lofexidine adjunctive therapy

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102
Q

Pregnancy and opioid substitution

A

Should be done as benefits outweigh risks, maintenance regimen, withdrawal not recommended in first and third trimester

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103
Q

Symptomatic opioid withdrawal treatment

A

Loperamide for diarrhoea, mebeverine for stomach cramps, metoclopramide for nausea, short acting benzo for insomnia

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104
Q

Opioid antagonist

A

Naloxone

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105
Q

Naltrexone action

A

Precipitates withdrawal symptoms , prevents relapse

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106
Q

Sedation for dental procedures

A

Diazepam and temazepam, effective anxiolytics, conscious sedation

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107
Q

Treating early stages of agitation/behavioural disturbance (mania)

A

Benzodiazepine

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108
Q

Antipsychotics used to treat acute mania/hypomania

A

Olanzapine 5-10mg, quetiapine, risperidone 2mg

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109
Q

Long term management of bipolar

A

Olanzapine in those that responded to it in a manic episode(monotherapy or with lithium/valproate)

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110
Q

Preventing bipolar

A

Lithium, (olanzapine, quetiapine) Carbamazepine if unresponsive to alternatives and have 4/more episodes a year), valproate also used

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111
Q

Use of valproate in bipolar

A

Treatment of manic episodes and prophylaxis of bipolar can add or switch to lithium/olanzaine if ineffective, can increase valproate dose during episodes of mania

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112
Q

Role of lithium in bipolar

A

Prophylaxis and treatment of mania, hypomania and depression in bipolar disorder (manic-depressive disorder), and in the prophylaxis and treatment of recurrent unipolar depression. Can be used concomitantly with antidepressants.

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113
Q

How long does it take for full lithium prophylactic effect

A

6-12 month window

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114
Q

Treating aggressive or self harming behaviour

A

Lithium

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115
Q

Positive symptoms

A

Thought disorder, hallucinations, and delusions

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116
Q

Negative symptoms

A

Apathy , social withdrawal

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117
Q

Antipsychotic and positive/negative

A

Relieve positive symptoms and prevent relapse

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118
Q

Negative symptoms treatment

A

Second gen antipsychotic

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119
Q

1st generation antipsychotic MOA

A

Blocks dopamine D2 brain receptors, not selective

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120
Q

Group 1 phenothiazine drugs and characteristics

A

Chlorpromazine, levomepromazine, and promazine,

pronounced sedative effects and moderate antimuscarinic and extrapyramidal side-effects

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121
Q

Group 2 phenothiazine drugs and characteristics

A

Least EPS, moderate sedative effects, pericyazine, more antimuscarinic

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122
Q

Group 3 phenothiazine drugs and characteristics

A

Most EPS, few sedative, few antimuscarinic, fluphenazine decanoate, perphenazine, prochlorperazine, and trifluoperazine,

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123
Q

What group of phenothiazine’s do butyrophenones e.g. Haloperidol clinically resemble

A

3

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124
Q

Second gen antipsychotics characteristic

A

Atypical, range of receptors, distinct profiles

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125
Q

Antipsychotics in the elderly

A

Not used in mild/moderate psychotic symptoms, initial dose half adult dose or less, review regularly

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126
Q

What drugs have most EPS symptoms

A

Phenothiazine (group 3 e.g. Prochlorperaxine), butyrophenones e.g. Haloperidol and 1st gen depot

127
Q

EPS symptoms

A

Parkinsonian (including tremor) dystonia, dyskinesia, akathisia, tardive dyskinesia

128
Q

Akathisia

A

Restlessness

129
Q

Tardive dyskinesia

A

Rhythmic, involuntary movements of tongue, face, jaw

130
Q

Dystonia

A

Abnormal face and body movements

131
Q

Antipsychotic side effects

A

EPS, hyperprolactinaemia, sexual dysfunction, CV, hyperglycaemia, weight gain, hypotension, neuroleptic malignant syndrome, blood dyscrasias, temperature change

132
Q

Why is hyperprolactinaemia a side effect

A

Dopamine inhibits prolactin release

133
Q

Clinical symptoms of hyperprolactinaemia

A

Sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea

134
Q

Sexual dysfunction and antipsychotic meds

A

Reduced libido, reduced ability to get an erection and ejaculation problems, switch or reduce dose if it occurs

135
Q

Drugs that cause sexual dysfunction

A

Haloperidol and risperidone

136
Q

What antipsychotics commonly cause weight gain

A

Clozapine and olanzapine

137
Q

What antipsychotic drugs commonly cause hyperglycaemia

A

Quetiapine, risperidone

138
Q

Antipsychotics least likely to cause diabetes

A

First gen, haloperidol, fluphenazine lowest risk. Amisulpride and aripiprazole are lowest of second gen

139
Q

Antipsychotics least likely to cause weight gain

A

Amisulpride, aripiprazole, haloperidol, sulpiride, and trifluoperazine

140
Q

Antipsychotics that cause postural hypotension

A

Clozapine, chlorpromazine, lurasidone, quetiapine

141
Q

Neuroleptic malignant syndrome effects

A

Hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating, and urinary incontinence

142
Q

Antipsychotics least likely to cause EPS

A

Second gen - aripiprazole, clozapine, olanzapine, and quetiapine

143
Q

Antipsychotics least likely to cause sexual dysfunction

A

Aripiprazole, quetiapine

144
Q

Antipsychotics that cause minimal hyperprolactinaemia

A

Second gen - aripiprazole, clozapine, olanzapine, and quetiapine

145
Q

What to use if unresponsive to schizophrenic treatment

A

Clozapine if 2 or more antipsychotics used for 6-8 weeks one of which being a 2nd gen, use the clozapine for 8-10 weeks and monitor

146
Q

Antipsychotic monitoring

A

FBC, Urea, electrolytes, LFT, blood lipids and weight at initiation then annually , maybe ECG and BP

147
Q

Fasting blood glucose monitoring with antipsychotic

A

Baseline, 4-6 months then yearly

148
Q

Blood lipids and weight monitoring with antipsychotic

A

Blood lipids and weight measured at 3 months then yearly

149
Q

Antipsychotics used for intractable hiccup

A

Chlorpromazine, haloperidol

150
Q

Downside of antipsychotic depot

A

Higher EPS

151
Q

Epilepsy drugs with a long half-life

A

Lamotrigine, perampanel, phenobarbital, and phenytoin,

152
Q

MHRA antiepileptic drug switching

A

Three categories, report via yellow card, brand name, characteristics differ

153
Q

Category 1

A

Carbamazepine, phenobarbital, phenytoin, primidone. By brand/manufacturer only

154
Q

Category 2

A

Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide. Clinical judgement, discussion with patient, history

155
Q

Category 3

A

Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin. Can be switched

156
Q

Epilepsy MHRA

A

Increased risk of suicide even one week into treatment refer mood changes, distressing thoughts, suicidal ideation

157
Q

DVLA Epilepsy

A

Not drive for 6 months if unprovoked , single isolated seizure

158
Q

Sleeping seizure DVLA policy

A

Can’t drive for a year unless there is a history of it only happening in sleep for >1 year

159
Q

Epilepsy and pregnancy

A

Teratogenic, especially valproate and topiramate (cleft hypospadias), pregnancy prevention programme warranted

160
Q

What to do in unplanned epilepsy pregnancy

A

Continue drugs, use folate

161
Q

Breast feeding and epilepsy

A

Continue drugs, watch for adverse symptoms in baby and withdrawal when feed stopped

162
Q

First line focal seizure treatment

A

Carbamazepine, lamotrigine

163
Q

Second line focal treatment

A

Sodium valproate, oxcarbazepine, levetiracetam

164
Q

Third line/adjunctive focal treatment

A

When monotherapy fails combine First/second line drugs or gabapentin, topiramate, clobazam, if it doesn’t work refer

165
Q

Generalised Tonic clonic treatment

A

Sodium valproate, lamotrigine if valproate ineffective or Carbamazepine, oxcarbazepine

166
Q

Downsides to non valproate tonic treatments

A

Lamotrigine , carbamazepine etc. may exacerbate myoclonic seizures and absence seizures

167
Q

Tonic clonic adjuncts

A

First/second line/clobazam/levetiracetam/topiramate

168
Q

Absence generalised first line

A

Ethosuximide, valproate if not the lamotrigine

169
Q

Absence adjuncts

A

Combination of two of ethosuximide, valproate, lamotrigine

170
Q

Myoclonic seizures

A

Combination of two of ethosuximide, valproate, lamotrigine

171
Q

Myoclonic second line treatment

A

Combine if not effective then specialist needed

172
Q

Carbamazepine treats what (+downsides)

A

Tonic-clonic, focal, exacerbates tonic, myoclonic and absence seizures so not given to these patients

173
Q

Oxcarbazepine treats what

A

Tonic-clonic, focal

174
Q

Ethosuximide treats what

A

Absence

175
Q

Gabapentin and pregabalin epilepsy treatment

A

Focal (pregabalin GAD)

176
Q

Lamotrigine treats what

A

Tonic-clonic, focal, absence in children, atonic (second line) may exacerbate myoclonic

177
Q

Valproate, lamotrigine relationship

A

Valproate increases plasma-lamotrigine

178
Q

Levetiracetam treatment

A

Focal, tonic-clonic, absence(adjunct), myoclonic

179
Q

Phenobarbital treatment

A

Tonic-clonic, focal - rebound seizures on withdrawal

180
Q

Primidone and phenobarbital relationship

A

Primidone converted to phenobarbital so lower dose needed initually

181
Q

Phenytoin treatment

A

Tonic-clonic, focal, narrow window, exacerbates absence, myoclonic

182
Q

Topiramate treatment

A

Tonic-clonic, focal, lennox-gastaut, atonic, absence, tonic, myoclonic

183
Q

Valproate treatment

A

Tonic-clonic, focal, myoclonic, absence

184
Q

Valproate monitoring

A

LFT, FBC

185
Q

Benzodiazepines and epilepsy

A

Clobazam=tonic-clonic , clonazepam = absence/myoclonic

186
Q

Status epilipticus treatment

A

Pyridoxine if needed, thiamine if alcohol abuse, lorazepam or diazepam given

187
Q

Febrile convulsions treatment

A

Paracetamol

188
Q

Status epilepticus treatment

A

Pyridoxine if needed, thiamine if alcohol abuse, lorazepam or diazepam given.Phenytoin

189
Q

Cluster headache treatment

A

Subcut sumatriptan or nasal spray or zolmitriptan nasal spray

190
Q

Cluster headache prophylaxis

A

Verapamil or lithium if attacks are frequent and last over 3 weeks, prednisolone can be used for short term prophylaxis alone or with verapamil, ergotamine can be used on an intermittent basis

191
Q

Drugs with antimuscarinic effects

A

Antidepressants ( amitriptyline, paroxetine), antihistamines (chlorphenamine, promethazine), antipsychotics (olanzapine, quetiapine) urinary antispasmodics ( solifenacin, tolterodine)

192
Q

Mild-moderate Alzheimer’s treatment

A

Donepezil hydrochloride, galantamine, or rivastigmine (acetylcholinesterase inhibitors)

193
Q

What to do if acetylcholinesterase inhibitors contraindicated

A

Memantine

194
Q

When is memantine used

A

Severe Alzheimer’s and as an adjunct

195
Q

Non-alzheimer’s dementia treatment (mild to moderate dementia with lewy body)

A

Donepezil or rivastigmine, galantamine if both are contraindicated

196
Q

What dementia is memantine and AChEi not recommended

A

Frontotemporal

197
Q

When should AChEi or memantine be considered for vascular dementia

A

Suspected co-morbid Alzheimer’s disease, Parkinson’s disease dementia, or dementia with Lewy bodies

198
Q

Dementia with lewy body treatment

A

AChEi if not then memantine

199
Q

Severe dementia with lewy body treatment

A

Rivastigmine , donepezil

200
Q

Effect of anticholinesterases on depolarising neuromuscular blocking drugs

A

Prolongs the action

201
Q

Effect of anticholinesterases on non-depolarising neuromuscular blocking drugs

A

Reverses effects

202
Q

Example of non-depolarising competitive neuromuscular blocking drug

A

Pancuronium bromide

203
Q

Two types of competitive muscle relaxants

A

Aminosteroid and benzylisoquinolinuum

204
Q

Depolarising neuromuscular blocking drugs

A

Suxamethonium chloride can be used with tracheal intubation

205
Q

Competitive muscle relaxants

A

Aminosteroid and benzylisoquinolinuum

206
Q

Caution to give for menstrual migraine

A

Medicine overuse

207
Q

Alternative menstrual migraine prophylaxis

A

Zolmitriptan or frovatriptan ( relies on regular menstrual cycle)

208
Q

Treating menstrual migraine prophylaxis

A

Frovatriptan +prophylactic treatment 2 days before until 3 days after menstuation (relies on regular menstrual cycle)

209
Q

When to use botox as a migraine prophylaxis in chronic migraine

A

3 or more oral prophylactic treatments failed

210
Q

What to use to prevent migraine if beta blocker unsuitable

A

Topiramate then TCA( amitriptyline), candesartan, valproate, pixotifen

211
Q

Beta blockers that can be used in migraines

A

Propranolol, metoprolol, atenolol, nadolol and timolol

212
Q

First line migraine prophylaxis

A

Propranolol

213
Q

Domperidone MHRA warning

A

Not to be used in those weighing <35KG

214
Q

Antiemetic to use in migraines

A

Metoclopramide and domperidone

215
Q

Metoclopramide cautions

A

EPS and neurological adverse effects according to MHRA

216
Q

Antiemetic’s that also treat headache

A

Metoclopramide, prochlorperazine

217
Q

What to do if patients does not respond to monotherapy for migraines

A

Naproxen + sumatriptan

218
Q

NSAIDS for vomiting migraine patients

A

Diclofenac suppositories

219
Q

NSAIDs for migraine treatment

A

Naproxen, tolfenamic acid and diclofenac

220
Q

Triptans for vomiting patients

A

Subcutaneous sumitriptan/nasal zolmitriptan

221
Q

Alternative triptans

A

Almotruptan, frovtriptan, xolmitiptan

222
Q

Triptan of choice for migraine

A

Sumatriptan

223
Q

How often can triptan (5HT) be repeated

A

2 hours after first dose with same or different drug

224
Q

When should triptans be taken

A

At the start of headache not aura

225
Q

Firstline acute migraine

A

Monotherapy aspirin, ibuprofen or triptan

226
Q

Lifestyle tips for migraine

A

Regular meals, hydration sleep exercise and headache diary to identify triggers for 8 weeks minimum

227
Q

Lifestyle migraine triggers

A

Stress, relaxation after stress, some foods and drinks, and bright lights

228
Q

How long do migraine aura symptoms last

A

Develop and resolve within an hour

229
Q

Migraine characteristics

A

Recurrent attacks of typically moderate to severe headaches that usually last between 4–72 hours. unilateral, pulsating, aggravated by routine physical activity, and may impact/prevent daily activities.
nausea and vomiting, photophobia and phonophobia

230
Q

Migraine with aura symptoms

A

Visual symptoms (zigzag or flickering lights, spots, lines, or loss of vision), sensory symptoms (pins and needles, or numbness), or dysphasia

231
Q

Chronic migraine

A

Headache >15 days a month and migraine characteristics on at least 8 days a month

232
Q

Episodic migraine definition

A

Less than 15 days a month

233
Q

Oestrogen and migraines

A

Drop in oestrogen just before menstruation is a trigger

234
Q

Chronic facial pain treatment

A

TCA (unlicensed)

235
Q

Treating trigeminal neuralgia

A

Surgery potentially carbamazepine/phenytoin

236
Q

Treating acute trigeminal neuralgia

A

Carbamazepine

237
Q

Corticosteroid role in neuropathic pain

A

Helps to relieve pressure in compression neuropathy and thereby reduce pain

238
Q

Topical neuropathic treatment

A

Lidocaine, capsaicin

239
Q

Neuropathic pain treatment

A

TCA - amitriptyline, pregabalin

240
Q

Treating insomnia associated with daytime anxiety

A

Long acting benzo e.g. Diazepam as a single night dose

241
Q

Z drugs and MOA

A

Zolpidem, zopiclone hypnotics - act on benzo receptor, not licensed for long term use

242
Q

Z drugs duration of action

A

Short

243
Q

Antihistamines side effects

A

Headache, psychomotor impairment and antimuscarinic effects.

244
Q

Antihistamine and insomnia things to know

A

Public can buy e.g. Promethazine, prolonged duration of action causes drowsiness the next day and its effect decreases after a few days of continued treatment

245
Q

Alcohol and sleep

A

Poor hypnotic as it has diuretic action, it disturbs sleep patterns and worsens sleep disorders

246
Q

Treating chronic anxiety

A

Benzodiazepines

247
Q

Anxiolytic benzo treatment regimen

A

Lowest dose for shortest time

248
Q

Who is benzo dependence most likely in

A

Alcohol or drug abuse

249
Q

Role of beta blockers in anxiety

A

Reduce autonomic symptoms such as palpitation and tremor

250
Q

Buspirone MOA

A

Acts on serotonin receptor

251
Q

When is buspirone used and how long does it take for an action

A

Anxiety, up to 2 weeks

252
Q

Tourette syndrome and related choreas treatment

A

Haloperidol, pimozide, clonidine, sulpiride, trihexyphenidyl, tetrabenazine (huntigton’s chorea)

253
Q

Essential tremor treatment

A

Primidone, propranolol/ beta blocker

254
Q

Parkinson’s pathophysiology

A

Death of dopaminergic cells in substantia nigra

255
Q

Non-motor parkinson’s disease symptoms

A

Dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss

256
Q

Classic Parkinson’s symptoms

A

Motor symptoms hypokinesia, bradykinesia, rigidity, rest tremor, postural instability

257
Q

Non-ergot-derived dopamine-receptor agonists

A

Pramipexole, ropinirole or rotigotine

258
Q

Monoamine-oxidase-B inhibitors used in Parkinsons

A

Rasagiline or selegiline hydrochloride

259
Q

What is prescribed for those whose motor symptoms decrease their quality of life

A

Levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa).

260
Q

What is prescribed for those whose motor symptoms don’t decrease their quality of life

A

Non-ergot-derived dopamine-receptor agonists

261
Q

Antiparkinsonian side effects

A

Psychotic symptoms, excessive sleepiness, sudden onset of sleep, impulse control, motor complications(levo), end of dose deterioration(levo), hallucinations

262
Q

What side effects are more common in dopamine receptor agonists

A

Everything except motor complications and dose deterioration

263
Q

Avoiding NMS and akinesia avoidance

A

Don’t suddenly stop antiparkinson drugs

264
Q

What to do if a patient develops dyskinesia or motor fluctuations despite optimal levodopa

A

Offer non ergot DRA’s, MoAbi or COMT as an adjunct if non-ergot fails then only then can you consider ergot’s

265
Q

Ergot DRA

A

Bromocriptine, cabergoline, pergolide

266
Q

What to do if dyskinesia persists despite ergot/non ergot/comt etc

A

Amantadine

267
Q

DVLA and parkinson’s

A

Inform DVLA and insurer

268
Q

Treating daytime sleepiness/sudden onset of sleep in parkinsons

A

Adjust treatment, give modafinil (review yearly) if reversible changes are excluded

269
Q

Treating nocturnal akinesia

A

Levodopa or DRA

270
Q

Postural hypotension in PD treatment

A

Midodrine if not then fludrocortisone

271
Q

Treating hallucinations due to PD drugs

A

If no cognitive impairment can use quetiapine or clozapine, other antipsychotics worsen motor functions

272
Q

Treating Rapid eye movement

A

Clonazepam/melatonin

273
Q

Treating drooling

A

Speech and language therapy if not the glycopyrronium bromide or botox

274
Q

Treating parkinson’s dementia

A

Acetylcholinesterase inhibitor if not tolerated then memantine

275
Q

Treating advanced PD

A

Apomorphine

276
Q

Apomorphine side effects

A

QT, nausea vomiting psychiatric, confusion, subcut nodules, impulse control disorders

277
Q

What is required when giving domperidone and apomorphine together and why

A

ECG due to QT prolongation risk

278
Q

Impulse control disorders

A

Compulsive gambling, hypersexuality, binge eating, or obsessive shopping

279
Q

Treating impulse control

A

Slowly reducing DRA

280
Q

What is chronic pain

A

Lasts longer than 12 weeks (then expected)

281
Q

Non-drug chronic treatment

A

Transcutaneous electrical nerve stimulation, exercise, CBT

282
Q

CBD and chronic pain

A

Not recommended unless as part of a clinical trial, if already using, it may be continued until they and appropriate clinician deem it suitable to stop

283
Q

First line WHO

A

Non-opioid + adjuvant if needed

284
Q

2nd line WHO

A

Opioid for mild/moderate pain +/- non-opioid +/- adjuvant.

285
Q

3rd line WHO

A

Opioid for moderate/severe pain +/- non-opioid +/- adjuvant

286
Q

What are anxiolytics

A

Sedatives that induce sleep when given at night

287
Q

What are hypnotics

A

Sedate when given during the day

288
Q

When are benzodiazepines indicated

A

Short term relief of severe/disabling/distressing anxiety - 2-4 weeks only

289
Q

What does abrupt benzodiazepine withdrawal result in

A

Confusion, toxic psychosis, convulsions, symptoms resembling delirium tremens

290
Q

When does long acting benzo act cause withdrawal symptoms

A

3 weeks after stopping

291
Q

When does short acting benzo act cause withdrawal symptoms

A

Within a day

292
Q

Benzo withdrawal symptoms

A

Insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances

293
Q

Short acting benzodiazepines

A

Loprazolam, lormetazepam, temazepam, no hangover effect but short acting benzos are more likely to have withdrawal phenomena

294
Q

Long acting benzodiazepines and effects

A

Nitrazepam flurazepam, residual effects the next day

295
Q

What hypnotics are used during dental procedures

A

Temazepam (diazepam if needed but has residual effect the next day)

296
Q

Risk of benzodiazepines and z drugs in older patients

A

Ataxic risk, confusion, falls and injury so should be avoided

297
Q

Risk of benzodiazepines and z drugs in older patients

A

Ataxic risk, confusion, falls and injury so should be avoided

298
Q

Drawback of long term hypnotic use

A

Withdrawal can cause rebound insomnia and withdrawal syndrome

299
Q

What antidepressant drugs can be used to promote sleep if taken at night

A

Clomipramine or mirtazapine

300
Q

What is short term insomnia and length of treatment

A

Emotional/serious medical illness, insomnia can last for a few weeks and recur, a hypnotic should not be given for more than three weeks ideally only one week and intermittent use is preferred

301
Q

What is transient insomnia

A

Normal sleeper but insomnia due to noise, shift work etc. Only one or two doses given

302
Q

When are long acting hypnotics preferred

A

Poor sleep maintenance, when anxiolytic is needed during the day

303
Q

When are short acting hypnotics preferred

A

When sedation the next day is undesirable or when prescribing for elderly patients

304
Q

Considerations before giving hypnotic for insomnia

A

Underlying cause, alcohol consumption, realistic sleep expectations

305
Q

How to prevent benzo withdrawal

A

For short acting taper within 2-4 weeks for long acting over a period of months by reducing dose by 500mcg-2mg every 2-4 weeks

306
Q

Benzo withdrawal symptoms

A

Insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances

307
Q

When does short acting benzo act cause withdrawal symptoms

A

Within a day

308
Q

When does long acting benzo act cause withdrawal symptoms

A

3 weeks after stopping

309
Q

What does abrupt benzodiazepine withdrawal result in

A

Confusion, toxic psychosis, convulsions, symptoms resembling delirium tremens

310
Q

When is benzodiazepine used to treat insomnia

A

Severe/disabling/extremely distressing insomnia

311
Q

When are benzodiazepines indicated

A

Short term relief of severe/disabling/distressing anxiety - 2-4 weeks only

312
Q

When and how long should anxiolytics/hypnotics be used for

A

When cause has been established and short term

313
Q

Problems with hypnotics/anxiolytics

A

Physical and psychological tolerance occur

BNF Chapters (11 decks)

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