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CNS November 23 > CNS Part 3 November 23 > Flashcards

CNS Part 3 November 23 Flashcards

1
Q

A103: What are the main MHRA alerts… Gabapentin

A

Specific to Gabapentin: 1.
risk of severe respiratory depression in adults and children
a. rare risk- even without concomitant opioid medicines
b. Impaired pts at higher risk- dose adjustment

  1. risk of abuse and dependence
    a. Schedule 3 drug, but is exempt from safe custody requirements
    b. fatal risks of interactions between gabapentin and alcohol,

and with other medicines that cause CNS depression, particularly opioids

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2
Q

A104: What are the main uses of valproate?

A

Epilepsy Migraine prophylaxis (unlicensed) Bipolar - manic phase only

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3
Q

A105: How does valproate work?

A

No one knows Mechanism not known

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4
Q

A106: Is valproate safe in pregnancy and breastfeeding?

A

NO, highly teratogenic + use in pregnancy leads to neuro defects and congenital malformations Avoid in women of child-bearing potential unless conditions of PPP are met Avoid in BF

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5
Q

A107: What are the main contraindications for valproate?

A

Acute porphyrias; As valproate is cautioned in liver toxicity it is therefore CI in: known or suspected mitochondrial disorders (higher rate of acute liver failure and liver-related deaths); personal or family history of severe hepatic dysfunction; urea cycle disorders (risk of hyperammonaemia)

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6
Q

A108: What are the main side effects of valproate?

A

Hepatic disorder (report ASAP) Blood disorder Pancreatitis

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7
Q

A109: What are the main drug interactions for valproate?

A

Effects of antipsychotics, MAOI and benzodiazepines increased when taking with valproate. Plasma concentrations of valproate reduced when taken with enzyme inducers (SCRAP BS GPS), especially phenytoin. Plasma concentrations of valproate increased when taken with enzyme inhibitors (GAVID SICKFACES.COM), especially erythromycin. Hepatotoxicity when taken with statins, alcohol, antifungals, flucloxacillin, tetracyclines, methotrexate and isoniazid and paracetamol Valproate decreases lamotrigine metabolism resulting in lamotrigine toxicity. Adjust dose. Valproate toxicity when given with topiramate. Carbapenems increase valproate metabolism (avoid it).

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8
Q

A110: What must be done before starting valproate?

A

Liver function before
and during first 6 months
Measure FBC
Ensure no undue potential for bleeding before starting and before surgery

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9
Q

A111: What must be monitored when on valproate and how often?

A
  1. liver function before therapy during first 6 months (esp pt at high risk of liver) 2. full blood count- assess bleeding risk before starting before surgery.
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10
Q

A112: What are the warning signs of taking valproate?

A

Pt of child bearing potential should be on the PPP program
Report signs of blood and hepatic disorders
Pancreatitis such as abdo pain,
N&v

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11
Q

A113: What’s the main patient advice you’d give someone if they were taking valproate?

A

Never stop treatment abruptly.

If you’re a woman, take effective contraception while taking valproate due to teratogenicity.

Use an IUD or other implant.

Oral contraceptives too risky due to DDI’s.

If you’re a woman and want a baby, see your GP asap.

See a doctor if feeling suicidal. If signs of liver toxicity such as jaundice, A&E.

If signs of blood disorders such as bruising, bleeding, sore throat etc, A&E.

take vitamin D and calcium if staying immobilised for a long time.

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12
Q

A114: What must pharmacists do when dispensing valproate?

A

Ensure female pts have a patient care and all important safety information including leaflets

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13
Q

A115: What’s the best method of contraception if a patient is on valproate?

A

‘highly effective’ contraception include: 1. male and female sterilisation (irreversible) 2. copper IUD ( long-acting reversible contraceptives) 3. levonorgestrel IUS 4. Progestogen-only implant (IMP). Females using the IMP must not take any interacting drugs that could reduce contraceptive effectiveness

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14
Q

A116: For patient on phenytoin and immobilised for a long time, what should you consider giving them?

A

Vitamin D supplement

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15
Q

A117: How long should it take to come off valproate?

A

At least 4 weeks. Obviously much longer if on a higher dose.

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16
Q

A118: Which antiepileptic drugs are the safest in terms of teratogenicity?

A

Lamotrigine Levetiracetam

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17
Q

A119: Which type of epilepsy is vigabatrin used for and which types of epilepsy it be avoided in?

A

USED for: Focal seizures and tonic clonic AVOIDED in: Absence, myoclonic, tonic and atonic

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18
Q

A120: Which side effect must patients report if they’re taking vigabatrin?

A

Report any new visual symptom such as ; Blurred vision

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19
Q

A121: Which type of epilepsy should pregabalin and gabapentin be avoided in?

A

Avoid in generalised seizures. Only suitable in focal seizures Memory Trick: GP NO MATA

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20
Q

A122: Which condition is gabapentin and pregabalin both licensed for?

A

Neuropathic pain

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21
Q

A123: What else can pregabalin be used for?

A

Generalised Anxiety Disorder (GAD) MT: PregAbalin=Panic Attack

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22
Q

A124: What is status epilepticus?

A

Medical emergency Seizures lasting > 5 minutes or when they’ re happening one after another with no recovery in between

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23
Q

A125: If someone has status epilepticus and is in hospital/resuscitation facilities, what should they be given?

A

This will all be done in a hospital setting: Start off by putting them in a position where they can’t be injured or harmed. Keep blood pressure and blood sugars stable. We give parenteral B1 if they are seizing because of alcohol abuse Give B6 if seizing due to B6 deficiency. If it last longer 5 minutes, send to hospital and give IV lorazepam. If seizures occur after 25 minutes or no improvement, then we give phenytoin, fosphenytoin or phenobarbital. If no control after 45 minutes, then we knock them out using thiopental, propofol or midazolam.

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24
Q

A126: If someone has status epilepticus and is NOT in hospital/ resuscitation facilities, what should they be given?

A

Diazepam rectal solution OR Midazolam oromucosal solution into buccal cavity

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25
Q

A127: What are the 7 main ways patients are managed in hospital if they have status epilepticus?

A
  1. Correct positioning to avoid injury, 2. oxygen therapy 3. Maintain blood pressure 4. Correct HYPOglycemia 5. Alcohol abuse -> parenteral thiamine 6. Pyridoxine deficiency -> pyridoxine 7. Duration > 5 mins -> IV lorazepam [hospital setting] a. repeated once after 10 mins if seizure occurs or fail to respond b. Alt. IV diazepam -> thrombophlebitis risk -> use diazepam emulsion c. IM diazepam or diazepam suppositories absorption is too slow
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26
Q

A128: What are the 2 main ways patients are managed in a non hospital setting if that have status epilepticus?

A

Rectal diazepam Buccal midazolam

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27
Q

A129: If there’s no recovery after 25 minutes or the seizure reoccurs, what should be given?

A

If seizures occur after 25 minutes or no improvement, then we give phenytoin, fosphenytoin or phenobarbital.

28
Q

A130: If there is no recovery after 45 minutes or the seizure reoccurs, what should be given?

A

Anaesthesia with thiopental sodium, midazolam or propofol (unlicensed indication) should be used with full intensive care support

29
Q

A131: If a patient has non convulsive status epilepticus, what should patients be given?

A

ORAL antiepileptics continued or started

30
Q

A132: If a patient has non convulsive status epilepticus, what should be given if treatment with oral antiepileptics doesn’t work?

A

If oral antiepileptics don’t work, treat the same way you would if they had convulsive status epilepticus. So in hospital: Start off by putting them in a position where they can’t be injured or harmed. Keep blood pressure and blood sugars stable. We give parenteral B1 if they are seizing because of alcohol abuse Give B6 if seizing due to B6 deficiency. If it last longer 5 minutes, send to hospital and give IV lorazepam. If seizures occur after 25 minutes or no improvement, then we give phenytoin, fosphenytoin or phenobarbital. If no control after 45 minutes, then we knock them out using thiopental, propofol or midazolam. ALTHOUGH ANESTHESIA IS RARELY USED In community Rectal diazepam or buccal midazolam

31
Q

A133: What are hypnotics and anxiolytics and what’s the difference?

A

Hypnotics: induce sleep and keep you relaxed during the day. Anxiolytics: induce sleep. They’re sedatives. Key difference is that hypnotics are more used in patients who have insomnia because of their anxiety while anxiolytics are used to help induce sleep generally.

32
Q

A134: What is the main problem associated with anxiolytics and hypnotics?

A

Dependence and tolerance

33
Q

A135: When prescribing anxiolytics and hypnotics, what should be done to prevent tolerance?

A

SHORT term LOW dose

34
Q

A136: What drug class is used as an anxiolytic and hypnotic?

A

Benzo’s

35
Q

A137: What drugs are no longer used as hypnotics and anxiolytics due to their side effects and dangers of overdose?

A

Barbiturates Meprobamate

36
Q

A138: How do benzos work?

A

Act at benzo receptors which are associated with GABA receptors

37
Q

A139: Give examples of benzodiazepines?

A

INTERMEDIATE acting: Chlordiazepoxide Nitrazepam Clobazam Diazepam Lormetazepam Loprazolam Oxazepam Temazepam ALPRAZOLAM LORAZEPAM MIDAZOLAM

38
Q

A140: If someone has insomnia, what must be done before starting drug treatment?

A

Always start off by figuring out what’s causing it Try and recommend lifestyle advice first like good sleep hygiene. If this fails, that’s when you commence with drug treatment.

39
Q

A141: What type of benzodiazepines are given to people with insomnia?

A

Generally we use benzo’s. However the type of benzo we use is based on the kind of insomnia that patient has and patient factors. Short acting (LLTOM): preferably in sleep onset insomnia and the elderly Long acting (CDN): preferably in patients who have anxiety as well because we want them to be relaxed 24/7 We could also use: Sedating antihistamines such as HD-CAP (Hydroxizine, Diphenhydramine, Chlorphenamine, Alimemazine and Promathazine) Melatonin

40
Q

A142: What dose adjustments must be made for the elderly and patients with liver impairments if they’re given benzos?

A

Short acting given to elderly and pts with liver impairments

41
Q

A143: What type of benzodiazepines are given to people with insomnia and anxiety?

A

Anxiolytics: long acting-diazepam Hypnotics: long acting-nitrazepam and flurazepam short acting-Loprazolam, lormetazepam, and temazepam

42
Q

A144: What is transient insomnia and what is used to treat it?

A

People who can’t sleep due to outside noises, jet lag or major disruptions in normal routines. Short acting benzo’s will fix this.

43
Q

A145: What is short term insomnia and what is used to treat it?

A

Insomnia due to emotional stress events Treated with short acting sedatives (LLTOM). Not treated for longer than a week.

44
Q

A146: Ideally, why should benzos and Z drugs be avoided in the elderly?

A

Greater risk of ataxia and confusion → leading to falls and injury

45
Q

A147: What benzodiazepines are preferred in the elderly because they have no hang over effect?

A

In general it’s best to avoid benzo’s and Z drugs in the elderly, but if you have to give them a benzo, give them a short acting one like LLTOM

46
Q

A148: Which 3 benzo’s have a short duration of action?

A

Temazapam Oxazapam Midazolam MT: TOM is short

47
Q

A149: If a patient has insomnia and day time anxiety, what should be given?

A

Long acting sedative/ benzodiazepine 1 night time dose of diazepam.

48
Q

A150: Which Z drugs are used to treat insomnia?

A

Zolpidem Zopiclone

49
Q

A151: What are the main problems associated with Z drugs?

A

Dependence has been reported in a small number of patients

50
Q

A152: What is the main side effect that patients complain about when taking zopiclone?

A

Taste disturbances: everything tastes metallic the next day. This is a very common side effect and it’s the main reason why patients often switch from zopiclone to zolpidem.

51
Q

A153: Which benzo is preferred in the elderly because it has no hang over effect?

A

In general it’s best to avoid benzo’s and Z drugs in the elderly, but if you have to give them a benzo, give them a short acting one like LLTOM

52
Q

A154: Which antihistamines can be used to treat insomnia?

A

Sedating: HD - CAP Hydroxyzine Diphenhydramine Chlorphenamine Alimemazine Promethazine

53
Q

A155: Which things can make insomnia worse?

A

Psychological factors: Anxiety, depression, Lifestyle factors: Excessive alcohol consumption, abuse of drugs, daytime cat-napping Physical factors: Chronic pain, pruritus (itching), dyspnoea (difficulty breathing) .

54
Q

A156: What pineal hormone is used to treat transient insomnia and adults over 55?

A

Melatonin

55
Q

A157: What is buspirone used for?

A

Anxiety

56
Q

A158: How does buspirone work?

A

Act at specific serotonin (5HT1A) receptors

57
Q

A159: What is the dependence and abuse potential of buspirone hydrochloride like?

A

The dependence and abuse potential of buspirone hydrochloride is low; however, licensed for short-term use only

58
Q

A160: How long will it take for buspirone work?

A

Up to 2 weeks

59
Q

A161: What does buspirone not alleviate?

A

Doesn’t alleviate benzo withdrawal symptoms so make sure patients are withdrawn from benzo’s slowly, before they start buspirone

60
Q

A162: What group of patients should barbiturates be avoided in?

A

Elderly

61
Q

A163: What barbiturate is used for anaesthesia?

A

Thiopental sodium very short-acting barbiturate

62
Q

A164: What kind of behaviour would indicate barbiturate toxicity?

A

Hostility and aggression However this most commonly happens when patients take barbiturates AND alcohol

63
Q

A165: What are benzodiazepines not appropriate to treat?

A

People who are stressed People who are miserable or depressed.

64
Q

A166: People with benzo dependence often have what other problems in terms of their lifestyle?

A

History of alcohol or drug abuse and with marked personality disorders

65
Q

A167: What cardiovascular drug is used to treat the physiological symptoms of anxiety?

A

Beta-blockers e.g propranolol palpitation, tremor, and tachycardia

66
Q

A168: Which benzodiazepines are long acting, short acting and intermediate acting?

A

Short Intermediate Long Temazepam Oxazepam Midazolam Alprazolam Loprazolam Lormetazepam MT: LLATOM Lorazepam Diazepam Nitrazepam Clobazam Chlordiazepoxide

CNS November 23 (7 decks)

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