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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
What are the key symptoms of serotonin syndrome?
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
26
Which antidepressant can be stopped abruptly? What circumstances would you taper with this drug?
Fluoxetine due to long half life | would taper if 40-60mg (higher doses)
27
What is the MHRA alert regarding anti-epileptic categories?
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
What are 2 key MHRA alerts for antiepileptic drugs
1. risk when switching introduced categories | 2. suicidal ideation
29
If someone has epilepsy-what are the rules regarding driving?
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
which antiepileptic drugs are now considered safer in pregnant as per updated guidance?
lamotrigine | levetiracetam
31
If a patient becomes pregnant/aims whilst on anti epileptic medication - what is done?
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
What is guidance regarding breastfeeding whilst on AEDs
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
What is anti-epileptic hypersensitivity syndrome and associated drugs?
1-8 weeks=rash, fever, lymphadenopathy, liver dysfunction, organ issues = CP3L drugs - Cross sensitivity with carbamazepine/ phenytoin - withdraw and do not re-initiate
34
What is a key side effect in antiepileptics most common with lamotrigine, carbamazepine, phenytoin
RASHES - SJS - phenytoin - refer-discontinue, Could re-introduce if mild - Screening Han chinese and Thai for the allele which increases risk of JS
35
Which anti-epileptics cause visual problems and what do they cause?
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
Which AED causes encephalopathic symptoms?
Vigabatrin. - marked sedation, confusion - withdraw/reduce
37
What is an MHRA alert with the use of gabapentin in epilepsy?
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
Which AEDs are enzyme inhibitors?
Sodium valproate
39
Which AEDs are enzyme inducers?
Carbamazepine phenytoin phenobarbital
40
What is 1st line AED for generalised tonic clonic seizures | and second line?
1st: sodium valproate 2nd: lamotrigine
41
What is 1st line in absence seizures
Ethosuximide | Sodium valp
42
What is 1st line for focal seizures
Carbamazepine | Lamotrigine
43
How long after stopping AEDs does a woman need to take additional precautions in sex for?
4 weeks
44
What contraception is preferred in women taking AEDs
Progesterone only injection depot IUD/IUS Additional barrier methods (not COC/POP/prog implant - enzyme inducers risk reduced contraceptive efficacy)
45
What is the interaction between lamotrigine and oestrogen based contraceptives
they reduce lamotrigine concentrations causing risk seizures
46
If a woman taking AEDs needs emergency contraception - what is most appt?
Copper IUD ideally | OR levonorgestrel 3g single dose [unlicensed]
47
What seizure types is phenytoin avoided in?
Absence or myoclonic- can exacerbate them
48
What is the therapeutic range for phenytoin
10-20mg/L
49
What is a key point regarding the pharmacokinetics of phenytoin?
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
What are the symptoms of phenytoin toxicity? SNATCHD
``` slurred speech nystagmus ataxia Confusion Hyperglycaemia Diplopia/blurred vision ```
51
What is a side effect of AEDs to counsel patients on regarding reporting signs of infections?
BLOOD DYSGRASIAS =reporting sore throat/mouth ulcers/bleeding/bruising/fever
52
Name 7 side effects of phenytoin
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
What is the risk with injectible phenytoin?
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
What is the risk of using IV infusion of Fosphenytoin?
Severe cardiac reactions-monitoring HR/BP/RR and for 30 mins after - always prescribe the dose and equivalent phenytoin
55
Name generic interactions of phenytoin
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
Name 5 side effects of carbamazepine and are they dose related? What can be done to reduce S/E?
Dose related! Can use MR preps to help ``` Blood dysgrasias Hepatotoxicity rash Hypersensitivity syndrome HYPONATRAEMIA ``` Others e.g. headache, drowsy, N&V
57
What are the symptoms of carbamazepine toxicity? I-HANDBAG
``` inco-ordination hyponatraemia ataxia nystagmus drowsiness blurred vision/diplopia Arrhythmias GI disturbances ```
58
Name general interactions of carbamazepine?
- 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
What are the actions of pharmacists when dispensing sodium valproate to girls/women?
- valproate patient card - reminder of risks of pregnancy and contraception - annual r/v - dispensing as whole pack and providing PIL - patient guide
60
What are the conditions of the PPP and Rx requirements for sodium valproate
7 day validity 30 day max supply Using highly effective contraception and on the PPP - excluded pregnancy
61
What are the 3 risk minimisation materials for patients as part of the PPP with sodium valproate?
Patient card patient guide risk acknowledgement form
62
What are the 4 main side effects of sodium valproate
Hepatotoxicity Blood dysgrasias Pancreatitis Reduced bone mineral density =need vit D if immobilised
63
What are interactions with sodium valproate
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
What is treatment of convulsive status epilepticus?
IV lorazepam | repeat after 10min
65
If convulsive seizures or febrile seizures in community - what is used as treatment?
Diazepam rectal solution or midazolam oromucosal solution | repeat ONCE after 10-15min if need
66
What is main s/e of lamotrigine
Skin rash

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