Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Paeds, MEP, OTC & Misc. > CNS bits and pieces! > Flashcards

CNS bits and pieces! Flashcards

1
Q

Prophylaxis and treatment of NV?

A

Antihistamines (cyclizine and promethazine)

Phenothiazines (prochlorperazine)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

NV in pregnancy

A

Avoid drug therapy

PROMETHAZINE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Post-operative NV

A

5HT3 receptor antagonist (ONDANSETRON)

Dexamethasone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Pre-operative anticipatory NV?

A

Lorazepam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Motion sickness?

A

Hyoscine HYDRObromide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Palliative care NV WITH OPIOID therapy?

A

Antipsychotic (Haloperidol and Levomepromazine)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Pts with PD NV?

A

Domperidone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

DOMPERIDONE - DA receptor antagonist

A

Doesn’t cross BBB, thus, good for PD

10mg TDS for 7 days maximum use

Only for 12+

Pts should be 35kg+

Causes QT prolongation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

METOCLOPRAMIDE - DA receptor antagonist

MHRA/CHM advice—Metoclopramide: risk of neurological adverse effects—restricted dose and duration of use

A

Causes extrapyramidal SEs - don’t use in PD

10mg TDS for a maximum of 5 days

18+

Metoclopramide can induce acute dystonic reactions involving facial and skeletal muscle spasms and oculogyric crises. These dystonic effects are more common in the young (especially girls and young women) and the very old; they usually occur shortly after starting treatment with metoclopramide and subside within 24 hours of stopping it.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Bipolar Disorder

A

Acute:
- Benzodiazepines
- Antipsychotic drugs => usually 2nd gen: Quetiapine, Olanzapine, or Risperidone
- Add in Li or Na Valproate

Prophylaxis:
- Carbamazepine, Na Valproate or Lithium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Lithium - SICK + TREMOR

A

Acute episodes = 0.8 - 1mmol/L
Therapeutic range = 0.4 - 1mmol/L

Measure levels 12h post dose

Monitor: weekly until stable, then 3 monthly for year 1, and then 6 monthly after that

Toxicity: REVeNG
Renal impairment - incontinence
Extrapyramidal SE - tremors
Visual Disturbances - blurred vision
Nervous System disorder - confusion and restlessness
GI disorder - diarrhoea and vomiting

SE:
- Thyroid disorder
- Nephrotoxicity
- Rhabdomyolysis
- QT prolongation
- Benign intracranial HTN
- 1st trimester - TERATOGENIC

Interactions:
- Hyponatraemia increases risk of toxicity - diuretics
- Salt imbalance
- Serotonin syndrome
- Extrapyridamil SEs
- QT prolongation
- Renally cleared drugs - increase risk of toxicity
- Reduced seizure threshold
- hypokalemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Dementia - TREATMENT - due to increasing ACh

A

Mild - moderate dementia = Acetylcholinesterase inhibitors:
- DONEPEZIL - neuroleptic malignant syndrome, take ON, can cause bradycardia - monitor pulse
- Rivastigmine - GI SEs (reduced in transdermal formulation)
- Galantamine - SJS, SCARs (Severe Cutaneous Adverse Reactions)

Moderate-severe dementia:
- Memantine
SE = balance disorders, constipation, dizziness/drowsiness

Aggravation treated with BENZODIAZEPINES (lorazepam) or ANTIPSYCHOTICS (risperidone)

SE: Increased ACh => parasympathetic SEs
Diarrhoea
Urinary incontinence
Muscle weakness
Bradycardia

Bronchospasms
Emesis
Lacrimation
Salivation

Stop treatment, treat the dehydration before reinitiating, amend the dose if needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

PD - due to alleviating DA

A
  1. Pts whose motor symptoms DECREASE their quality of life:
    LEVODOPA + CARBIDOPA / BENSERAZIDE
  2. Pts whose motor symptoms don’t affect their quality of life:
    LEVODOPA
    NON-ERGOT-DERIVED DA RECEPTOR = pramipexole, ropinirole, rotigotine
    MOA-B INHIBITORS - selegiline
  3. Pts who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should add an adjuvant to the levodopa:
    - non-ergot DA receptor agonists, MAOI-B inhibitors
    - COMT inhibitors
  4. If symptoms are not adequately controlled with a non-ergot-derived DA receptor agonist as an adjunct to levodopa:
    - Ergot-derived DA receptor agonists
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

LEVODOPA

A

Carbidopa / benserazide is added in order to prevent the breakdown of levodopa before it crosses into the brain

  • Impulse disorders = pathological gambling; binge eating; hypersexuality
  • end of dose deterioration (wearing off) - effects of levodopa wear off before the next dose is due. If too much off-periods, use MR preps

Apomorphine is used in advanced disease for predictable “off” periods - as it has a high incidence of NV, thus, put pt on domperidone (peripheral D2 blocker) at least 2 days prior to starting. MHRA warning as if QT prolongation is found, STOP ASAP - must assess cardiac risk factors and ECG monitoring.

  • Sudden onset of sleep = treat with modafinil (increased risk of congenital malformations if used during pregnancy)

SE: N (can take with food), postural hypotension, somnolence, urine discolouration etc.

  • red urine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Non-ergot-derived DA receptor

A

Pramipexole, ropinorole, rotigotine

  • impulse disorders
  • sudden onset of sleep
  • hypotension

This can be added to levodopa therapy to increase the “on” time.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

MAOI-B inhibitors

A

Selegiline - may cause insomnia due to amphetamine-like metabolites, Rasagiline

  • causes hypertensive crisis if given with phenylephrine pseudoephedrine, xylometazoline

Interacts with tyramine-rich foods:
- Mature cheese
- Salami
- Marmite
- Yeast
- Tofu

SSRIs = can cause serotonin syndrome
SE = can increase levodopa SEs, thus, reduce levodopa dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

COMT inhibitors

A

Entacapone - red-brown urine, tolcapone - hepatotoxic; taken 2 - 3h apart from iron preps

Increases sympathetic SEs - increase in CVD effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Ergot-derived DA receptor agonists

A

Bromocriptine, Cabergoline - licensed to suppress lactation

Pulmonary reactions = report SoB, chest pain, cough

Pericardial reactions = chest pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Non-motor symptoms in PD

A
  1. daytime sleepiness and sudden onset of sleep
    MODAFINIL
  2. Nocturnal akinesia
    1st line: LEVODOPA or PO DA-receptor agonists
    2nd line: rotigotine
  3. Postural hypotension
    MIDODRINE
    2nd (unlicensed): fludrocortisone
  4. Psychotic symptoms
    No cognitive impairment: QUETIAPINE (unlicensed)
    If standard treatment isn’t effective: CLOZAPINE
  5. Rapid eye movement sleep behaviour disorder
    CLONAZEPAM or MELATONIN (unlicensed indications)
  6. Drooling of saliva
    1st line: GLYCOPYRRONIUM BROMIDE (unlicensed indication)
    2nd line: Botox (botulinum toxin type A)
  7. PD Dementia
    1st line: acetylcholinesterase inhibitors
    2nd line: memantine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Psychosis and Schizophrenia
Positive: delusions, hallucinations, disorganization
Negative: Social withdrawal, neglect, poor hygiene

2nd gen antipsychotics

A

Amisulpride
Aripiprazole
Clozapine
Olanzapine
Quetiapine
Risperidone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Psychosis and Schizophrenia - 1st gen antipsychotics - PHENOTHIAZINES

A

Group 1: Chlorpromazine, Levomepromazine, promazine
MOST SEDATION, moderate antimuscarinic and EPSEs

Group 2: Pericyazine
Moderate sedation, LEAST EPSEs

Group 3: Fluphenazine, prochlorperazine and trifluoperazine
Moderate sedation, HIGH EPSEs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Psychosis and Schizophrenia - 1st gen antipsychotics - THIOXANTHENES

A

Flupentixol, Zuclopenthixol

Moderate sedation, antimuscarinic effects, EPSEs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Psychosis and Schizophrenia - 1st gen antipsychotics - BUTYROPHENONES

A

Benperidol, Haloperidol

Moderate sedation, HIGH EPSEs (similar to Phenothiazines Group 3)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Psychosis and Schizophrenia - 1st gen antipsychotics - Others

A

Pimozide, sulpiride

Reduced sedation, antimuscarinic effects and EPSEs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Antipsychotics SEs

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Antipsychotic monitoring

A

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

27
Q

CLOZAPINE - used in resistant schizophrenia: only used when 2+ antipsychotics including one 2nd gen has been used for 6-8 wks each!

A

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.

28
Q

Anxiety - Treatment

A

Acute: Benzodiazepines

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

29
Q

Benzodiazepines

A

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

30
Q

Benzodiazepines withdrawal

A

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)

31
Q

Sleep disorders - Benzos and Z-drugs

A

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

32
Q

ADHD - Treatment

A

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!

33
Q

ADHD - Methylphenidate (CD-2)

A

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

34
Q

ADHD - Lisdexamfetamine (CD-2) and Dexamfetamine (CD-2)

A

Similar SE to M.

Overdose:
- causes: wakefulness, excessive activity, paranoia, hallucinations and HTN
- followed by: exhaustion, convulsions, hyperthermia and coma

Similar monitoring to M.

35
Q

Depression - Treatment

A

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

36
Q

Depression - Antidepressants

A

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

37
Q

SSRIs - better tolerated and safer in overdose

Max OD doses:
Sertraline: 200mg
Fluoxetine: 60mg
Citalopram: 40mg (20mg in elderly)
Paroxetine: 50mg (40mg in elderly)

A

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

38
Q

TCAs

A

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

39
Q

MAOIs - specialist use only!

A

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.

40
Q

MAOI washout periods!

A

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

41
Q

Mirtazapine

Max dose: 45mg

A

ADR: Blood dyscrasias, Exanthema, Sedation

CI: x < 18 years

Interactions:
- Increase mirtazapine levels => Antifungals, cimetidine, erythromycin

42
Q

SNRIs - Serotonin and NA re-uptake inhibitors

Max dose:
Venlafaxine: 375mg
Duloxetine: 60mg

A

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

43
Q

Alcohol dependence - Treatment

A

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)

44
Q

Nicotine Dependence - Treatment

A

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

45
Q

Opioid dependence - treatment

A

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

46
Q

Migraines - ACUTE treatment

A

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

47
Q

Migraine - PROPHYLAXIS TREATMENT

A

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

48
Q

Headache types - Cluster, Trigeminal neuralgia, Tension

A

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

49
Q

Epilepsy - FOCAL SEIZURES (April 2022)

A

1st: Lamotrigine or Levetiracetam (added)

2nd: Zonisamide, Oxcarbazepine, Carbamazepine

ZOCALL.

50
Q

Epilepsy - Generalised Seizures (April 2022) M.A.T.T.A.

A

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

51
Q

Status Epilepticus (April 2022)

A

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

52
Q

Epilepsy - Pregnancy

A
  • 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!!!
53
Q

Epilepsy - Breastfeeding

A

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

54
Q

Epilepsy - Driving

A

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

55
Q

Epilepsy - Antiepileptic drugs

A

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

56
Q

Carbamazepine - 4 - 12mg/L

Pre-treatment screening:
Test for HLA-B1502 allele in individuals of Han Chinese or Thai origin (avoid unless no alternative—risk of Stevens-Johnson syndrome in presence of HLA-B1502 allele).

A

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

57
Q

Phenytoin - 10 - 20 mg/L

100 mg of phenytoin sodium = 92 mg phenytoin base.

Pre-treatment screening:
HLAB* 1502 allele in individuals of Han Chinese or Thai origin—avoid unless essential (increased risk of Stevens- Johnson syndrome).

A

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

58
Q

Na Valproate

A

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.

59
Q

Anti-epileptic interactions - Carbamazepine, Phenytoin & Na Valproate

A

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)

60
Q

Anti-epileptic SEs = Carbamazepine, Phenytoin, Na Valproate

A

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

61
Q

Anti-epileptic SEs - other drugs

A

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

62
Q

Topiramate SE?

A

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.

63
Q

Levetiracetam

A

Aggression - KEPPRA RAGE

Nasopharyngitis

Paeds, MEP, OTC & Misc. (28 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions