CNS bits and pieces! Flashcards

Question

Antipsychotics SEs

Answer 1

Extrapyramidal SEs: Most in phenothiazine group 3 (prochlorperazine) and butyrophenones (Haloperidol) Hyperprolactinaemia: Least in ARIPIPRAZOLE. Risperidone, amisulpride, sulpiride, and first-generation antipsychotic drugs are most likely to cause symptomatic hyperprolactinaemia. Hyperprolactinaemia is very rare with aripiprazole, asenapine, cariprazine, clozapine, and quetiapine treatment. Sexual dysfunction: ALL antipsychotics => Risperidone, haloperidol, and olanzapine have a higher prevalence to cause sexual dysfunction. The antipsychotic drugs with the lowest risk of sexual dysfunction are aripiprazole and quetiapine. Cardiovascular SEs: QT prolongation most common with PIMOZIDE and HALOPERIDOL Hypotension: CLOZAPINE and QUETIAPINE Hyperglycaemia: (CiROQ) - Clozapine, Risperidone, Olanzapine, Quetiapine. Of the first-generation antipsychotic drugs, fluphenazine decanoate and HALOPERIDOL have the lowest risk. AMISULPIRIDE and ARIPIPRAZOLE have the lowest risk of diabetes of second-generation antipsychotic drugs. Weight gain: (COW) Clozapine and Olanzapine = Weight gain Neruleptic Malignant Syndrome: Stop treatment => treat with BROMOCRIPTINE => Should resolve in 5 - 7 days

Answer 2

Weight: Start, weekly for the first 6 weeks, at 12 weeks, at 1 year, then yearly Fasting blood glucose, HbA1c and blood lipid concentrations: Start, at 12 weeks, at 1 year, and then yearly ECG: Before initiation BP: Start, at 12 weeks, at 1 year, then yearly FBC, U&Es and LFTs: Start, then yearly

Answer 3

If missed more than 2 doses - specialist reinitation Monitor leucocyte and differential blood counts: - weekly for 18 weeks - fortnightly until 1 year - monthly Blood lipids and weight: - baseline - 3 months for the 1st year - Yearly Fasting blood glucose: - baseline - then every 4-6 months - yearly SEs: - Myocarditis and Cardiomyopathy => report and stop on tachycardia, most common in first 2 months - Agranulocytes and Neutropenia => Monitor leucocyte and differential blood counts as previously mentioned - GI disturbances: Report and stop on CONSTIPATION => intestinal block! Common SE: - feeling drowsy - making extra saliva and dribbling, or a dry mouth - loss of appetite - fast HR - feeling sick - constipation - gaining weight - being able to hold your urine, alt. hard going to the toilet - dizziness - jerking or fits - blurred vision - Avoid alcohol as can make you more drowsy - Changing the amount of caffeine that I drink (tea, coffee, or cola) can affect the amount in the blood. - Initial treatment - avoid driving - Smoker = increase dose; stop smoking = decrease dose at cigarette smoke breaks down the drug more quickly. On planned withdrawal reduce dose over 1–2 weeks to avoid risk of rebound psychosis. If abrupt withdrawal necessary observe patient carefully.

Answer 4

Acute: Benzodiazepines Chronic: SSRI - Sertraline, Citalopram, Escitalopram, Fluoxetine; Propranolol - alleviates PHYSICAL symptoms only

Answer 5

Long acting benzodiazepines => diazepam, alprazolam, chlordiazepoxide, clobazam Short-acting benzodiazepines => lorazepam, oxazepam - These preferred in pts with hepatic impairment and elderly - They carry a GREATER RISK OF WITHDRAWAL symptoms (use for 2-4 weeks) Can induced HEPATIC COMA, esp in long-acting benzos => treat with lowest dose for shortest period Can cause PARADOXICAL effects: aggression, hostility, talkative, anxious, excited Sedation increased with use of alcohol, CNS depressants or CYP enzyme inhibitors - avoided in concomitant use Avoid driving if feeling drowsy => they've a legal driving limit (COLD FeeT) = Clonazepam, Oazapam, Lorazepam, Diazepam, Flunitrazepam and Temazepam Overdose treated by FLUMAZENIL

Answer 6

Dependence = anxiety, sweating, weight loss, tremors, loss of appetite 1) Convert all meds to ON dose of diazepam 2) Reduce by 1-2mg (1/10th on larger doses) every 2-4 weeks - only further withdraw if the pt has overcome any withdrawal symptoms 3) Reduce further (0.5mg near the end)

Answer 7

Long-acting benzodiazepines = Nitrazepam, diazepam and flurazepam - Higher hangover effect on the following day - Sleep maintenance Short-acting benzodiazepines = loprazolam, lormetazepam, and temazepam - Little or no hangover effect - Used for sleep onset - Higher chance of withdrawal symptoms Z-drugs = Zolpidem, Zopiclone - increases GABA => CNS depression - Dependency occurs within 3-14 days of use - should be used for 4 wks max - should be taken intermittently - Benzos + Z-drugs => avoid in the elderly due to risk of falls and injury - Paradoxical SEs = staying awake at night - Drowsiness - Dependence

Answer 8

Kid > 5 years: 1. Methylphenidate 2. If a 6-week trial of M at the max tolerated dose doesn't reduce symptoms - switch to Lisdexamfetamine Kids who are intolerant of both M and L: 3. Atomoxetine or Guanfacine Adults: 1. Methylphenidate or Lisdexafetamine - Dexamfetaine if pt can't tolerate long duration of action 2. Atomoxetine - causes QT prolongation, hepatotoxicity and suicidal idealation MR preps are preferred due to their pharmacokinetic profile, convenience and improved adherence MR preps should be prescribed by BRAND!

Answer 9

CNS stimulant High BP, tachycardia, arrhythmias Behaviour / mood changes, drowsiness and sleep disorders Decreased appetite, growth retardation and Wt loss Monitor: pulse, BP, psychiatric symptoms, appetite, weight and height initiation - recorded at initiation of therapy, following each dose adjustment, and at least 6 monthly thereafter

Answer 10

Similar SE to M. Overdose: - causes: wakefulness, excessive activity, paranoia, hallucinations and HTN - followed by: exhaustion, convulsions, hyperthermia and coma Similar monitoring to M.

Answer 11

Mild: CBT Moderate-Severe: Antidepressants Pt may feel worse in the first 1-2 weeks Should be taken for 4 weeks (6 weeks in the elderly) b4 deemed ineffective Take for 6 months after remission, 1 year in elderly, 2 years in recurrent

Answer 12

1st: SSRI 2nd: Increase SSRI dosage, change SSRI, Mirtazapine, MAOI (specialist), TCA or Venlafaxine (severe) 3rd: Add in another class: Li or antipsychotic Use electroconvulsive therapy in severe refractory depression

Answer 13

1st line for treating depression Sertraline = safest in pts with cardiac events Fluoxetine for kids < 17 years CI: poorly controlled epilepsy SE: - GI - diarrhoea and V - appetite and weight gain - sexual dysfunction - risk of bleed - insomnia - take OM - QT prolongation - Esp with citalopram and escitalopram Interactions: - CYP enzyme inhibitors => AVOID grapefruit! - CYP enzyme inducers - QT prolongation drugs - amiodarone, sotolol, quinolones - Drugs increase the risk of bleed - Hyponatraemia - carbazmazepine and diuretics - Serotonin syndrome = St John's Wort, Triptans, Opioids - Tamoxifen = avoid with FLUOXETINE and PAROXETINE as it decreases the efficacy of Tamoxifen Serotonin syndrome: - Cognitive effects = headache, agitation, hypomania, coma, confusion - autonomic effects = sweating, hyperthermia, N, diarrhoea - neuromuscular excitation = myoclonus, tremor, teeth grinding Caused by: - SSRIs, TCAs, MAOIs - Triptans - Tramadol - Li

Answer 14

Sedating - better for agitated and anxious pts - Amitriptyline, Clomipramine, Dosulepin and Trazodone Less sedating - better for withdrawn and apathetic pts - Imipramine, Lofepramine and Nortiptyline Amitriptyline + Dosulepin = dangerous in overdosage - not recommended for the treatment of depression SE: CASHH - Cardiac events - Anti-muscarinic - Seizures - Hypotension - Hallucinations DANGEROUS IN OVERDOSE Interactions: - CYP enzymes inhibitors - CYP enzymes inducers - QT prolongation = amiodarone, sotalol, quinolones - anti-muscarinic drugs - anti-hypertensive drugs - serotonin syndrome

Answer 15

Causes HEPATOTOXICITY - Phenelzine + isocarboxazid Hypertensive crisis - don't give OTC pseudoephedrine! Avoid tyramine-rich foods! Tranylcypromine + Clomipramine = FATAL! severe toxic reaction when given with Tranylcypromine. Manufacturer advises avoid and for 14 days after stopping the MAOI.

Answer 16

MAOI => 2 weeks => Other antidepressants MAOI => 3 weeks => Clomipramine or imipramine MAOI => 2 weeks => new MAOI ------------------------------------------------------------- Moclobemide => 0 weeks => new MAOI TCA or related antidepressant => 1-2 weeks => MAOI Clomipramine or imipramine => 3 weeks => MAOI SSRI or related antidepressant => 1 week => MAOI Fluoxetine => 5 weeks => MAOI ? Sertraline => 2 weeks => MAOI

Answer 17

ADR: Blood dyscrasias, Exanthema, Sedation CI: x < 18 years Interactions: - Increase mirtazapine levels => Antifungals, cimetidine, erythromycin

Answer 18

MHRA: SSRI/SNSRI antidepressant medicines: small increased risk of postpartum haemorrhage when used in the month before delivery - venlafaxine. ADR: Hypertension, somnolence C/I: Uncontrolled hypertension Interactions: - Diltiazem, Verapamil => venlafaxine levels increase! - Drugs increasing QT interval - Drugs increasing bleeding risk

Answer 19

CBT or ACAMPROSATE or NALTREXONE (Alt: disulfram) Withdrawal symptoms = Long-acting benzos, for example, CHLORDIAZEPOXIDE or DIAZEPAM (Alt: Carbamazepine or Clomethiazole) Delirium = LORAZEPAM Wernicke's Encephalopathy: Thiamine (Vit B1)

Answer 20

VARENICLINE - avoid in epilepsy, CVS disease and psychiatric illness BUPROPION - Avoid in psychiatric illness, seizures and eating disorders - causes serotonin syndrome NRT: - Patch (16h patch if pregnant or experiencing nightmares) AND - Short-term reliever = lozenges, gum, sublingual tabs, inhalator, nasal spray and oral spray

Answer 21

Treatment for opioid dependence should be initiated under the supervision of an appropriately qualified prescriber On FP10MDA form - max supply of 14 DAYS 3 or more missed doses = refer pt back to the specialist Treatment should be continued throughout pregnancy NALOXONE can be prescribed as well if the pt is at a high risk of overdose Buprenorphine: - less sedating than methadone - milder withdrawal symptoms - lower risk of overdose - SUBOXONE - buprenorphine with naloxone - when there's a risk of injecting Methadone: - causes QT prolongation - carefully titrated according to pt's needs

Answer 22

Treat with ASPIRIN, IBUPROFEN, or a 5HT1-receptor agonist (SUMATRIPTAN favourable) Take as soon as the pt knows that they are developing a migraine With aura: Triptan taken at the start of the headache and not at the start of the aura Triptan can be repeated after 2h (4h in Naratriptan) ONLY if there has been a response to first dose but not fully adequate Use SOLUBLE PARACETAMOL if unable to take first line options Antiemetics may be require: EMTOCLOPRAMIDE or PROCHLORPERAZINE

Answer 23

1st: PROPRANOLOL If CI, use METOPROLOL or NADOLOL AMITRIPTYLINE is effective - use less sedating TCA if amitriptyline is not tolerated Na Valproate, Pizotifen or Botox used normally under specialist

Answer 24

Cluster headaches - Intense unilateral pain in or around ONE eye - Acute: SC SUMATRIPTAN (Nasal sumatriptan / Zolmitriptan given if unavailable) - Prophylaxis: Verapamil, Li, Prednisolone or Ergotamine tartate (rarely use) Trigeminal Neuralgia: - Severe facial pain like having an electric shock in the jaw, teeth or gums - Treat with CARBAMAZEPINE Tension headache: - Bilateral throbbing pain like a tight band around your head - PARACETAMOL or IBUPROFEN

Answer 25

1st: Lamotrigine or Levetiracetam (added) 2nd: Zonisamide, Oxcarbazepine, Carbamazepine ZOCALL.

Answer 26

Myoclonic: 1st: Na Val 2nd: Levetiracetam Atonic: 1st: Na Val 2nd: Lamotrigine Add-on options: - Rufinamide - Clobazam - Topiramate Tonic: 1st: Na Val 2nd: Lamotrigine Add-on options: - Rufinamide - Clobazam - Topiramate Tonic-Clonic: 1st: Na Valproate 2nd: Lamotrigine or Levetiracetam (added unlicensed use) Add on treatment if mono-therapy is unsuccessful: - Clobazam - Lamotrigine - Levetiracetam - Perampanel - Na Val => except in women/girls of childbearing age - Topiramate Absence: 1st: Ethosuximide 2nd or add on: Na Val (if they present with tonic or clonic seizures with the absence seizure) 3rd or add on: Lamotrigine or Levetiracetam

Answer 27

Seizures lasting longer than 5 mins: - IV LORAZEPAM (repeated once within 5 - 10mins if seizures recur or fail to respond) - IV diazepam (avoid due to high risk of thrombophlebitis) If seizure fails to respond 25 mins after onset: - IV: PHENYTOIN SODIUM, Na Val, Levetiracetam (this drug has fewer AE’s and a quicker administering rate) If these measures fail to control seizures 45mins: - Phenobarbital or general anaesthetic such as Propofol If in community/resus not available: - BUCCAL MIDAZOLAM or RECTAL DIAZEPAM Add on drugs: - parenteral THIAMINE given if alcohol abuse is suspected - Give PYRIDOXINE if cause by pyridoxine deficiency

Answer 28

- Folic acid given to reducce risk of neural tube defects in first trimester - Vit K injection administered at birth to minimise risk of neonatal haemorrhage - Most risk = Na Val (PPP) - Topiramate = Cleft Palate!!!

Answer 29

Encouraged to breast feed High presence in milk (PLEZ) = Primidone, Lamotrigine, Ethosuximide, Zonisamide Risk of drowsiness (BPP) = Benzodiazepines, Phenobarbital, Primidone Withdrawal effects (mum suddenly stops breastfeeding) (BPPL) = Benzodiazepines, Phenobarbital, Primidone, Lamotrigine

Answer 30

Driver must stop driving STAT and inform DVLA First unprovoked / single isolated = 6 MONTHS Established epilepsy = 1 YEAR (or pattern of seizures established for 1 year wit no impact on consciousness) Medication change / withdrawal: - shouldn't drive for 6 MONTHS AFTER LAST DOSE - Seizure occurs: license revoked for 1 year, reinstated for after 6 months if treatment resumed and no further seizures occurred

Answer 31

CAT 1: CPPP CAT 2: Clobazam, Clonazepam, Lamotrigine, Oxcarbazepine, Perampanel, Fufinamide, Topiramate, Valproate, Zonisamide CAT 3: No need to be on brand => Brivaracetam, Ethosuximide, Gabapentin, Lacosamide, Levetiracetam, Pregabalin, Tiagabine, Vigabatrin

Answer 32

Caution—cross-sensitivity reported with oxcarbazepine, phenytoin, primidone, and phenobarbital Toxicity: HANDBAG Hyponatraemia Ataxia Nystagmus Drowsiness Blurred vision Arrhythmias GI disturbances Consider vitamin D supplementation in patients who are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium. Blood, hepatic, or skin disorders: Carbamazepine should be withdrawn immediately in cases of aggravated liver dysfunction or acute liver disease. Leucopenia that is severe, progressive, or associated with clinical symptoms requires withdrawal (if necessary under cover of a suitable alternative). Overdose = use activated charcoal! Therapeutic drug monitoring: Plasma concentration for optimum response 4–12 mg/litre (20–50 micromol/litre) measured after 1–2 weeks. Monitoring of patient parameters: Manufacturer recommends blood counts and hepatic and renal function tests

Answer 33

Cross-sensitivity reported with carbamazepine. Toxicity: SNACHD Slurred speech Nystagmus Ataxia Confusion Hyperglycaemia Double vision - diplopia Enteral feeding = interrupt feeding for 2 hours before and after dose MHRA advises consider vitamin D supplementation in patients who are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium. IM phenytoin should not be used (absorption is slow and erratic) Monitoring of patient parameters: - Manufacturer recommends blood counts (but evidence of practical value uncertain). With intravenous use: - Monitor ECG and BP

Answer 34

MHRA/CHM advice: Valproate medicines: contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met MHRA/CHM advice: Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme CI: Acute porphyrias Cautions: SLE The MHRA advises consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium. Hepatic dysfunction: Withdraw treatment immediately if persistent vomiting and abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness, or loss of seizure control. Pancreatitis: Discontinue treatment if symptoms of pancreatitis develop. Monitoring of patient parameters: - Monitor liver function before therapy and during first 6 months especially in patients most at risk. - Measure full blood count and ensure no undue potential for bleeding before starting and before surgery. Patients or their carers should be told how to recognise signs and symptoms of blood or liver disorders and advised to seek immediate medical attention if symptoms develop. Patients or their carers should be told how to recognise signs and symptoms of pancreatitis and advised to seek immediate medical attention if symptoms such as abdominal pain, nausea, or vomiting develop. Effect on laboratory tests = False-positive urine tests for ketones. Treatment cessation: Avoid abrupt withdrawal; if treatment with valproate is stopped, reduce the dose gradually over at least 4 weeks.

Answer 35

Hepatotoxicty = Amiodarone, Itraconazole, Macrolides, Alcohol CYP Enzyme = Inducers (Phenytoin, Phenobarbital, Carbamazepine); Inhibitors (Na Valproate) Drugs that lower the seizure threshold: Tramadol, Theophylline, Quinolones Carbamazepine = hyponatraemic drug (SSRIs, Diuretics) Phenytoin = Anti-folate (Methotrexate, Trimethoprim)

Answer 36

ALL: - MHRA: Depression and suicide - Hepatotoxicity - Hypersensitivity - Blood dyscrasia - Vitamin D deficiency Carbamazepine = Hyponatraemia, odema Phenytoin = Coarsening appearance, facial hair (hirsutism) Na Val = Pancreatitis, teratogenic

Answer 37

Hypersensitivity (CP3L) = Carbamazepine, Phenytoin, Phenobarbital, Primidone, Lamotrigine Skin rash = Lamotrigine => SJS Blood dyscrasis (C.VET.PLZ) = Carbamazepine, Valproate, Ethosuximide, Topiramte, Phenytoin, Lamotrigine, Zonisamide Eye disorder = Vigabatrin (reduced visual field); Topiramate (secondary glaucoma) Encephalopathy = Vigabatrin Resp depression = Gabapentin, Pregabalin

Answer 38

Increased risk of kidney stones Wt loss Cognitive slowing Speech impairment Pins and needles (paraesthesia) MHRA: Topamax - start of safety review triggered by a study reporting an increased risk of neurodevelopmental disabilities in children with prenatal exposure - dose-dependent association between prenatal exposure and an increased risk of autism spectrum disorders, intellectual disability, and neurodevelopmental disorders in children.

Answer 39

Aggression - KEPPRA RAGE Nasopharyngitis