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PRE-REG own > CNS - Depression & epilepsy > Flashcards

CNS - Depression & epilepsy Flashcards

1
Q

what are 5 side effects of antidepressants (general)

A 
SSSH:
Hyponatraemia
Sexual dysfunction
suicidal ideation
sedation
serotonin syndrome
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2
Q

What are symptoms of hyponatraemia to look out for in SSRIs/anti-depressants

A

Drowsiness
confusion
muscle cramps
convulsions

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3
Q

If a patient is on MAOI and want to switch - what is washout period?

A

2 weeks

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4
Q

If a patient is on SSRI and need to switch, what is washout period?
what is the exception?

A

1 week

sertraline: 2 weeks

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5
Q

How long do you have to wait before switching climipramine /imipramine?

A

3 weeks

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6
Q

How long do you have to wait to switch from TCAs

A

1-2 weeks

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7
Q

which MAOI doesnt require a washout?

A

Moclobemide. - short acting/reversible

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8
Q

Which antidepressants have higher risk of withdrawal symptoms?

A

Venlafaxine

paroxetine

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9
Q

which is theo only antidepressant licensed in children

A

Fluoxetine

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10
Q

which antidepressant is choice in history of Myocardial infarction/unstable angina?

A

Sertraline

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11
Q

Which antidepressants cause QT prolongation

A

Citalopram
escitalopram
TCAss
venlafaxine

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12
Q

What are side effects of SSRIs? (GASH)

A

GI disturbances

apetite loss/weight changes

serotonin syndrome

Hypersensitivity reactions - if rash - Stop

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13
Q

What action is to be taken if someone on SSRI experiences a rash

A

Stop - risk of systemic rxn or vasculitis

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14
Q

What are key warnings/cautions for SSRIs

A 
Bleeding risk increased
QT prolongation
Reduced seizure threshold 
Movement disorders/EPS/tremors
Hyponatraemia
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15
Q

What are some interactions of SSRIs

A

Enzyme inhibitors
Other drugs increasing bleed risk
Other drugs prolonging QT interval
Other drugs causing hypokalaemia as this can risk QT/TDP
Drugs causing hyponatraemia e.g. loop/thiazide, desmopressin, carbamazepine, NSAIDS

increased serotonin syndrome risk e.g. sumatriptan, tramadol, ondansetron, selegiline, TCA/MAOI, SJW, amfetamines

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16
Q

What is an MHRA warning about SSRIs

A

risk post partum haemorrhage when used in 1 month before delivery (pregnancy) - benefit Vs risk, dont stop if high risk thrombosis but be aware

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17
Q

What are the less sedating TCAs and when would you give these?

A

Imipramine

lofepramine

nortryptylline

Use in the withdrawn/apethtic patients

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18
Q

What are key side effects of TCAs

A

Cardiotoxicity
sedating
seizure risk
antimuscarinic side effects e.g. dry mouth etc

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19
Q

What are interactions of TCAs

A 
Enzyme inhibitors e.g. cimetidine
Enzyme inducers e.g. carbamazepine 
Drugs increasing hyponatraemia
Drugs prolonging QT
Drugs causing hypotension - AB, BB, ACE,CCB, L-dopa, antipsychotics, NSAIDS, SGLT2, diuretics, PDI5
- antimsucarinic drugs 
- lithium
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20
Q

What are key OTC interactions and food of MAOIs

A

Pseudoephedrine, dextromethorphan

Food: cheese, wine, meat stocks, fermented soya

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21
Q

what are the irrversible MAOIS

A

Phenelzine (hepatotoxic)
isocarboxazid (hepatotoxic)
tranylcypromine

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22
Q

If a patient is on TCAs and experiences this symptom. - it is risk hypertensive crisis - what symptom is this?

A

Throbbing headache

  • discontinue
  • e.g. tranylcypromide
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23
Q

what is a counselling point for maoi

A
  • avoiding the high tyramine rich foods
  • reporting throbbing headache
  • sedation and key s/e
  • eating fresh food, not stale/going off
  • avoiding alcohol
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24
Q

Common s/e of mitrazepine?

A 
Weight gain +increased apetite 
sedation 
oedema
constipation 
drowsy

BLOOD DYSGRASIAS!!!

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25
Q

What are the key symptoms of serotonin syndrome?

A
  1. neuromuscular hyperactivity - tremor, rigidity, clonus
  2. Autonomic dysfunction e.g. tachy, BP changes, shivering, diarrhoeae
  3. Altered mental state e.g. agitation, confusion, mania
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26
Q

Which antidepressant can be stopped abruptly? What circumstances would you taper with this drug?

A

Fluoxetine due to long half life

would taper if 40-60mg (higher doses)

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27
Q

What is the MHRA alert regarding anti-epileptic categories?

A

harm when switching between products
Category 1= maintain on same product (generic or brand and rx should state) = CP3 = carbamazepine, phenytoin, phenobarbital, primidone

Cat 2= clinical decision/judgement = valproate, lamotrigine, topiramate, clonazepam

Cat 3=no need to maintain = levetiracetam, gabapentin, pregabalin, ethosuximide

28
Q

What are 2 key MHRA alerts for antiepileptic drugs

A
  1. risk when switching introduced categories

2. suicidal ideation

29
Q

If someone has epilepsy-what are the rules regarding driving?

A

If seizure=stop driving and tell DVLA-no driving for >6 months if seizure free
If established epilepsy must be seizure free for 1 year, have an established pattern with no influence on consciousness, and no history of unprovoked seizures,

  • shouldnt drive if: dose change/withdrawal/sleep seizures,
  • no driving until 6 M after last dose and no seizure
30
Q

which antiepileptic drugs are now considered safer in pregnant as per updated guidance?

A

lamotrigine

levetiracetam

31
Q

If a patient becomes pregnant/aims whilst on anti epileptic medication - what is done?

A

Do not withdraw unless specialist -so referral needed -

  • Withdraw and resume after 1st trim or monotherapy - some would need dose adjustments (CPL)
  • would need to notify UK epilepsy and pregnancy register
  • also initiate folic acid 5mg daily before conception until week 12
  • vit K injection newborn
32
Q

What is guidance regarding breastfeeding whilst on AEDs

A

safe and encouraged - just need to monitor for any drowsiness/weight gain/feeding issues

  • ZELP high amounts in milk
  • Phenobarbital and lamotrirgine may accumulate due to slower metabolism
33
Q

What is anti-epileptic hypersensitivity syndrome and associated drugs?

A

1-8 weeks=rash, fever, lymphadenopathy, liver dysfunction, organ issues
= CP3L drugs
- Cross sensitivity with carbamazepine/ phenytoin
- withdraw and do not re-initiate

34
Q

What is a key side effect in antiepileptics most common with lamotrigine, carbamazepine, phenytoin

A

RASHES

  • SJS
  • phenytoin - refer-discontinue, Could re-introduce if mild
  • Screening Han chinese and Thai for the allele which increases risk of JS
35
Q

Which anti-epileptics cause visual problems and what do they cause?

A

Vigabatrin = visual field defects

Topiramate =acute myopia shortsightedness with secondary angle closure glaucoma - signs of raised IOP report e.g. intense pain/headache/tender

36
Q

Which AED causes encephalopathic symptoms?

A

Vigabatrin. - marked sedation, confusion - withdraw/reduce

37
Q

What is an MHRA alert with the use of gabapentin in epilepsy?

A

Risk of severe resp depression even without concomittant opioids - higher risk with elderly/poor resp function/renal imp and concomittant CNS depressing drugs e.g. opioids, BZs, antipsychotics, lithium, alcohol, antidepressants

38
Q

Which AEDs are enzyme inhibitors?

A

Sodium valproate

39
Q

Which AEDs are enzyme inducers?

A

Carbamazepine
phenytoin
phenobarbital

40
Q

What is 1st line AED for generalised tonic clonic seizures

and second line?

A

1st: sodium valproate
2nd: lamotrigine

41
Q

What is 1st line in absence seizures

A

Ethosuximide

Sodium valp

42
Q

What is 1st line for focal seizures

A

Carbamazepine

Lamotrigine

43
Q

How long after stopping AEDs does a woman need to take additional precautions in sex for?

A

4 weeks

44
Q

What contraception is preferred in women taking AEDs

A

Progesterone only injection depot
IUD/IUS
Additional barrier methods

(not COC/POP/prog implant - enzyme inducers risk reduced contraceptive efficacy)

45
Q

What is the interaction between lamotrigine and oestrogen based contraceptives

A

they reduce lamotrigine concentrations causing risk seizures

46
Q

If a woman taking AEDs needs emergency contraception - what is most appt?

A

Copper IUD ideally

OR levonorgestrel 3g single dose [unlicensed]

47
Q

What seizure types is phenytoin avoided in?

A

Absence or myoclonic- can exacerbate them

48
Q

What is the therapeutic range for phenytoin

A

10-20mg/L

49
Q

What is a key point regarding the pharmacokinetics of phenytoin?

A

Highly protein bound so if protein binding reduced then higher levels free drug e.g. pregnancy, children <3M, elderly, liver failure -early toxicity

Non-linear relationship between dose and Cp so missed doss=large changes in conc

50
Q

What are the symptoms of phenytoin toxicity? SNATCHD

A 
slurred speech
nystagmus 
ataxia
Confusion
Hyperglycaemia 
Diplopia/blurred vision
51
Q

What is a side effect of AEDs to counsel patients on regarding reporting signs of infections?

A

BLOOD DYSGRASIAS =reporting sore throat/mouth ulcers/bleeding/bruising/fever

52
Q

Name 7 side effects of phenytoin

A
  1. blood dysgrasias - antifolate
  2. changes in apearance - hirutism(hair growth), gingival hyperplasia/acne/facial features
  3. suicidal ideation
  4. osteomalacia and rickets-vit D
  5. hepatotoxicity - report signs and symptoms
  6. rashes
  7. hypersensitivity syndrome
53
Q

What is the risk with injectible phenytoin?

A

NHS improvement patient safety alert - risks of severe harm in eerrors
- if too rapid=CNS and CVS depression - monitor ECG and BP, if bradycardia/hypotension occur then reduce rate

54
Q

What is the risk of using IV infusion of Fosphenytoin?

A

Severe cardiac reactions-monitoring HR/BP/RR and for 30 mins after
- always prescribe the dose and equivalent phenytoin

55
Q

Name generic interactions of phenytoin

A
  1. Enzyme inhibitors causing toxicity
  2. enzyme inducers causing seizures
  3. ciprofloxacin, NSAIDS, theophylline, tramadol, SSRI, antipsychotics = seizure threshold reduced
  4. MTX, trimethoprim - anti-folate
  5. phenytoin as enzyme inducer can cause reduced efficacy of other drugs e.g. contraception, warfarin, CCS, levothyroxine
56
Q

Name 5 side effects of carbamazepine and are they dose related?
What can be done to reduce S/E?

A

Dose related! Can use MR preps to help

Blood dysgrasias
Hepatotoxicity
rash
Hypersensitivity syndrome
HYPONATRAEMIA

Others e.g. headache, drowsy, N&V

57
Q

What are the symptoms of carbamazepine toxicity?

I-HANDBAG

A 
inco-ordination
hyponatraemia
ataxia
nystagmus
drowsiness
blurred vision/diplopia
Arrhythmias
GI disturbances
58
Q

Name general interactions of carbamazepine?

A
  • Enzyme inhibitors- increasing carb
  • enzyme inducers-reducing
  • reduced seizure threshold drugs
  • hepatotoxicity drugs-tetracyclines, mtx, sulfalsalazine,statins, fluconazole
  • Increased hyponatraemia risk e.g. SSRI, diuretics, TCA, aldosterone antg, nsaids

Carb is also enzyme inducer so reduces efficacy of warfarin, contraceptives, levothyroxine, statins, ccb, ccs

59
Q

What are the actions of pharmacists when dispensing sodium valproate to girls/women?

A
  • valproate patient card
  • reminder of risks of pregnancy and contraception
  • annual r/v
  • dispensing as whole pack and providing PIL
  • patient guide
60
Q

What are the conditions of the PPP and Rx requirements for sodium valproate

A

7 day validity
30 day max supply
Using highly effective contraception and on the PPP - excluded pregnancy

61
Q

What are the 3 risk minimisation materials for patients as part of the PPP with sodium valproate?

A

Patient card
patient guide
risk acknowledgement form

62
Q

What are the 4 main side effects of sodium valproate

A

Hepatotoxicity

Blood dysgrasias

Pancreatitis

Reduced bone mineral density =need vit D if immobilised

63
Q

What are interactions with sodium valproate

A

Reduced seizure threshold drugs
hepatotoxic drugs (statins, carb, tetracyclines, fuconazole, mtx, sulfasalazine)
Enzyme inhibitor so increases toxicity of other drugs e.g. lamotrigine, phenobarb

64
Q

What is treatment of convulsive status epilepticus?

A

IV lorazepam

repeat after 10min

65
Q

If convulsive seizures or febrile seizures in community - what is used as treatment?

A

Diazepam rectal solution or midazolam oromucosal solution

repeat ONCE after 10-15min if need

66
Q

What is main s/e of lamotrigine

A

Skin rash

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