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CNS November 23 > CNS Part 4 November 23 > Flashcards

CNS Part 4 November 23 Flashcards

1
Q

Question

A

Answer

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2
Q

A169: If someone wants to come off benzodiazepines, can they stop abruptly? R

A

Never stop abruptly if used long term as it can cause withdrawal symptoms which can last for months such as: Anxiety, Loss of appetite, Insomnia, Delirium tremens, Convulsions, Confusion

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3
Q

A170: What symptoms would you see in abrupt withdrawal of benzos? (M)

A

Confusion, Toxic psychosis, Convulsions, Condition resembling delirium tremens (like alcohol withdrawal)

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4
Q

A171: What are the symptoms of benzodiazepine withdrawal syndrome? S

A

Confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens, insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, perceptual disturbances

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5
Q

A172: How quickly would you see symptoms of withdrawal if patients stop long acting and short acting benzodiazepines? G

A

LA: any time up to 3 weeks after stopping, SA: within one day

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6
Q

Q173: How long will it take to come off benzodiazepines completely? R

A

2-4 weeks with short-term users, Months with long-term users, Decrease dose in steps of 1-2mg every 2-4 weeks.

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7
Q

A174: What is given to help patients coming off benzo? (M)

A

Diazepam

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8
Q

A175: What type of anxiety are benzo’s avoided in? S

A

Chronic anxiety

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9
Q

Q176: What are the other uses of benzodiazepines? G

A

Alcohol withdrawal, Epilepsy, Muscle spasms, Insomnia, Anxiety

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10
Q

A177: When are short-acting benzo’s used instead of long-acting benzo’s? R

A

Short-acting preferred in: Elderly, Hepatic impairment

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11
Q

A178: What are the 4 main cautions of benzos? (M)

A

Avoid prolonged use, Avoid abrupt withdrawal, Pts with a history of drug/alcohol dependence, Paradoxical effects

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12
Q

A179: What are the paradoxical effects of benzo’s and what is done to prevent this? S

A

Hostility + aggression, Talkativeness + excitement vs. Antisocial, Anxiety + perceptual disorder, Adjust dose UP or DOWN to reduce the paradoxical effects

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13
Q

A180: What are the main side effects of benzo’s? G

A

Dizziness and drowsiness, Reduced alertness, Anxiety, Altered mood, Fatigue, GI disorders, Sleep disorder, Muscle weakness

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14
Q

A181: What are the main contraindications of benzo’s? R

A

Sleep apnea syndrome, Unstable myasthenia gravis, Acute pulmonary insufficiency

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15
Q

A182: Are benzos safe in pregnancy and breastfeeding? (M)

A

Neonatal withdrawal symptoms when used during pregnancy → avoid regular use and use only if there is a clear indication e.g. seizure control, High doses during later pregnancy/ labor = cause neonatal hypothermia, hypotonia (decreased muscle tone) & respiratory depression, Present in breast milk = avoided if possible during breastfeeding

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16
Q

A183: What is the patient and carer advice around benzodiazepines? S

A

Drowsiness may persist the next day, Affects performance of skilled tasks (e.g., driving), Effects enhanced by alcohol

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17
Q

A184: Which benzo’s are used in hepatic impairment? G

A

Short-acting, LLTOM

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18
Q

A185: Which benzo’s can be used in hepatic impairment? R

A

Short-acting ones are safer in general

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19
Q

A186: What is ADHD? (M)

A

Behavioral syndrome characterized by hyperactivity, impulsivity, and inattention which can lead to social, educational, or occupational impairment

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20
Q

A187: What are the main aims of treating ADHD? S

A

Reduce functional impairment, severity of symptoms, Improve quality of life

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21
Q

A188: What drugs are used 1st line for ADHD? G

A

Methylphenidate or lisdexamfetamine

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22
Q

A189: What are the main counseling points for methylphenidate? R

A

Affects driving so don’t drive if feeling weird, Enhanced by alcohol so don’t drink

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23
Q

A190: What’s given if methylphenidate and lisdexamfetamine are contraindicated or not tolerated? (M)

A

Atomoxetine or dexamfetamine

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24
Q

A191: What is used to treat ADHD if patients have a history of being drug abusers? S

A

Atomoxetine?

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25
Q

A192: What are the side effects of atomoxetine? G

A

Anxiety, N&V, Antimuscarinic SE, Sexual dysfunction, Cardiac: Arrhythmias and palpitations, Depression, Dizziness, and drowsiness

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26
Q

A193: What is bipolar disorder? R

A

A long-term period of extreme mood swings/ energy swings, Low points: experiencing depression, High points: experiencing mania and hypomania (having too much ambition to the point of self-destruction), Mania is dangerous because people who have manic episodes can do things that can destroy their lives. Total disinhibition is dangerous. Remember that.

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27
Q

A194: What are the main symptoms of mania? (M)

A

Grand ideas about yourself and your own self-importance, Increased energy & less sleep, More talkative than usual, Full of new ideas and plans. Often the plans are grandiose and unrealistic, Irritation or agitation, Wanting to do a lot of pleasurable things → e.g., spend a lot of money, less sexual inhibition, drink a lot of alcohol, or take illegal drugs

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28
Q

A195: What are the symptoms in depression if they have bipolar? S

A

Low mood for most of the day nearly every day, Loss of enjoyment and interest in life even for activities that you normally enjoy, Abnormal sadness often with weepiness, Feeling guilty, worthless or useless, Poor motivation, even simple tasks seem difficult, Poor concentration: it may be difficult to read, work etc, Sleeping problems

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29
Q

A196: What drugs are used in bipolar? G

A

Lithium, Valproate, Carbamazepine, Antipsychotics, Benzo’s, Memory trick: LV CAB

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30
Q

A197: Which drug can be used in both the manic and depressive states in bipolar? R

A

Lithium, All the other drugs are only used in controlling mania

31
Q

A198: How long should treatment be continued if someone has bipolar? (M)

A

Continue long-term treatment of bipolar for at least 2 years from last manic episode and up to 5 years if pt has risk factors for relapse

32
Q

A199: When should antidepressants be avoided in treating bipolar? S

A

Patients with rapid cycling bipolar disorder (4+ effective episodes), Recent hx of HYPOnatremia, Rapid mood fluctuation

33
Q

A200: Why can benzo’s be used to treat bipolar? G

A

For agitation and behavioral disturbances, People with bipolar can experience this in the manic phase and hence benzo’s will be suitable for them.

34
Q

A201: When are antipsychotics used to treat bipolar? R

A

If the patient is in any manic state, Antipsychotics are used to knock some sense into them so they can go back to normal, If this isn’t working, that’s when we add valproate or lithium.

35
Q

A202: When is lithium or valproate used to treat bipolar? (M)

A

When response is inadequate with olanzapine, quetiapine, or risperidone for mania & hypomania

36
Q

A203: When is carbamazepine used to treat bipolar? S

A

Prophylaxis of bipolar disorder (manic depressive disorder), Pts with rapid cycling manic depressive illness (4+ effective episodes)

37
Q

A204: What are the main uses of lithium? G

A

Treatment and prevention of all of the following: Mania, Bipolar (any phase), Self-harming and aggressive behavior, Recurrent depression

38
Q

A205: Is lithium safe in pregnancy and breastfeeding? R

A

Pregnancy: Avoid in 1st trimester (teratogenic), Increase dose requirements in later trimesters but can abruptly go back to normal dose after delivery, Monitor plasma levels of lithium during pregnancy. BF: Avoid

39
Q

A206: What are the main contraindications for lithium? (M)

A

Dehydration, Low sodium diets (increases lithium conc), Untreated hypothyroidism - lithium affects T4 production and can cause hypothyroidism, Significant renal impairment, Cardiac disease - lithium causes arrhythmias, Addison’s disease

40
Q

A207: What are the main side effects of lithium? S

A

GI disturbance, CNS: drowsiness, confusion, unsteadiness, Electrolyte imbalance, HYPOthyroidism (weight gain, fatigue, hair loss), Cardiomyopathy & AV block, Arrhythmia, Lower seizure threshold (caution with epileptics), Tremor, movement disorders, muscle weakness, Leukocytosis, Renal dysfunction (polydipsia-excessive thirst), Memory loss, Skin reaction/skin ulcers, Vision disorders (blurred vision), Intracranial HYPERtension (persistent headache & visual disturbance), QT interval prolongation

41
Q

A208: What are the main cautions of lithium? G

A

Current treatment with diuretics that cause hyponatremia (causes lithium toxicity), Current treatment with drugs that cause QT prolongation (arrhythmias), Epilepsy (reduced seizure threshold), Elderly (need lower dose), Current cardiac disease

42
Q

A209: What are the main drug interactions for lithium? R

A

EPS side effects when taken with antipsychotics, Arrhythmias with anything that causes prolonged QT such as antipsychotics, macrolides, amiodarone, digoxin, quinolones and SSRI’s, Lithium conc increased when given with PAND MAT: PPI’s, ACE, NSAIDs, Trimethoprim, Metronidazole, Amiodarone and Tetracyclines, Lithium conc decreased when taking: theophylline and carbonic anhydrase inhibitors, Neurotoxicity when given with CAST (DIVE): Carbamazepine, Antipsychotics, SSRI’s, Triptans and Diltiazem and Verapamil

43
Q

A210: What must be done before starting lithium? (M)

A

Assess renal, cardiac and thyroid function before treatment, ECG recommended in pts with cardiovascular risk or risk factors for it, Body weight or BMI, serum electrolytes, and FBC should also be measured before starting treatment

44
Q

A211: What are the main warning signs of lithium? S

A

Visual disturbances, CNS disturbances (confusion and drowsiness increasing to lack of coordination, restlessness, stupor); abnormal reflexes, Myoclonus (involuntary muscle jerk), With severe overdosage: seizures, cardiac arrhythmias (including sino-atrial block, bradycardia and first-degree heart block), blood pressure changes, circulatory failure, renal failure, coma and sudden death reported, Levels (0.4-1mmol/L + 0.8-1mmol/L), Increased urination (polyuria), Incontinence, Thirst, Tremor, Teratogenic, HYPOthyroidism, HYPERnatraemia, Interactions: (NSAIDs, ACEi, Diuretics, Antacids), Upset stomach (vomiting, diarrhea), Muscle weakness, Skin effects (acne, psoriasis)

45
Q

A212: What’s the therapeutic range for lithium? G

A

0.4-1mmol/L (maintenance and the elderly), 0.8-1mmol/L (acute mania)

46
Q

A213: What are the monitoring requirements of lithium and how often? R

A

Lithium conc: Every 3 months for the 1st year then every 6 months after. Renal function: Every 6 months. Cardiac function: Every 6 months. Thyroid function: Every 6 months.

47
Q

A214: What must be done before starting lithium? (M)

A

Assess renal, cardiac and thyroid function before treatment, ECG recommended in pts with cardiovascular risk or risk factors for it, Body weight or BMI, serum electrolytes, and FBC should also be measured before starting treatment

48
Q

A215: What’s the main patient and carer advice to give to patients on lithium? S

A

Report signs and symptoms of: lithium toxicity, HYPOthyroidism (fatigue, weight gain. hair loss), renal dysfunction (including polyuria and polydipsia), benign intraCRANIAL HYPERtension (persistent headache and visual disturbance). Maintain adequate fluid intake (esp during infection/hot weather), Otc meds: look out for interactions, Driving: avoid if drowsy, Do not stop unless advised, Avoid alcohol, avoid dietary changes that reduce or increase sodium intake, Maintain the same brand, A lithium treatment pack should be: given to patients on initiation: patient information booklet, lithium alert card, and a record book for tracking serum-lithium concentration

49
Q

A216: Which drugs raise lithium concentrations? G

A

PAND MAT: PPI’s, ACE inhibitors, NSAID’s, Diuretics (loop and thiazide), Metronidazole, Amiodarone, Tetracyclines

50
Q

A217: Which drugs decrease lithium concentration?

A

Theophylline, Carbonic anhydrase inhibitors, Na antacids

51
Q

A218: What electrolyte imbalance predisposes someone to lithium toxicity? (M)

A

Hyponatremia, Avoid dehydration or anything that changes sodium levels

52
Q

A219: Which drugs can increase neurotoxicity when taking lithium? S

A

Carbamazepine, Antipsychotics (quetiapine, risperidone), SSRIs, Triptans, CCBs - verapamil, diltiazem, Most drugs prolong QT interval when taken with lithium by causing HYPOkalemia

53
Q

A220: Which drugs can cause serotonin syndrome? G

A

All antidepressants, Linezolid, Buspirone, Lithium, Tramadol, St johns wort, Methadone, Triptans, Fentanyl

54
Q

A221: What are the 3 major classes of antidepressants? R

A

SSRI - Selective Serotonin Reuptake Inhibitor, TCA - Tricyclic Antidepressants, MAOI - Monoamine Oxidase Inhibitors

55
Q

A222: Give examples of antidepressants that don’t fit the 3 major classes of antidepressants? (M)

A

SNRIs e.g. venlafaxine and duloxetine, Tetracyclic antidepressants e.g. trazodone and mianserin

56
Q

A223: Give examples of TCA’s? S

A

Tricyclic Antidepressants: Amitriptyline - neuropathic pain, Clomipramine, Dosulepin, Doxepin, Imipramine most antimuscarinic, Lofepramine - liver toxicity, Nortriptyline, Trimipramine

57
Q

A224: Give examples of tetracycline antidepressants? G

A

Trazodone, Mianserin, Mirtazapine

58
Q

A225: Give examples of SSRI’s? R

A

Sertraline, Paroxetine, Escitalopram, Citalopram, Fluoxetine

59
Q

A226: Give examples of MAOIs? (M)

A

Phenelzine, Isocarboxazid, Tranylcypromine, Reversible inhibitors (RIMA): Moclobemide - no washout period - licensed for social anxiety disorder

60
Q

A227: Which MAOI is the only one that is a reversible inhibitor and has no washout period? S

A

Moclobemide - licensed for social anxiety disorder

61
Q

A228: Which MAOI’s are not reversible inhibitors and do have a washout period? G

A

PIT: Phenelzine, Isocarboxazid, Tranylcypromine

62
Q

A229: What OTC medication should patients avoid if they’re taking MAOI’s? R

A

Sympathomimetics and adrenaline - get a hypertensive crisis, Avoid ephedrine, pseudoephedrine, and phenylephrine

63
Q

A230: What type of depression are antidepressants used for? (M)

A

Moderate to severe depression

64
Q

A231: What is used in the treatment of mild depression?

A

Psychological therapy should be considered initially, St. John’s wort (Hypericum perforatum) on sale to the public for treating mild depression. It should NOT be prescribed or recommended - potent inducer

65
Q

A232: How long does it take for antidepressants to start working? G

A

2 weeks

66
Q

A233: What are the main issues that patients experience when taking antidepressants in the 1st few weeks? R

A

Agitation, Anxiety, Suicidal thoughts, All of these paradoxical effects happen within the 1st few weeks, and it’s important patients see a doctor, especially if they want to kill themselves.

67
Q

A234: Is there a difference in the efficacy of the different classes of antidepressants? (M)

A

Similar efficacy but different side effects

68
Q

A235: Which antidepressant class is used 1st line and why? S

A

SSRIs, better tolerated, are safer in overdose

69
Q

A236: What is the main side effect that’s associated with all antidepressants? G

A

Hyponatremia

70
Q

A237: What are the main signs of hyponatremia? R

A

Stupor/ coma, Anorexia, Lethargy, Tendon reflexes decrease, Limp muscles, Orthostatic hypotension, Seizures, Stomach cramps, Memory trick: Hyponatremia = SALT LOSS, Memory trick: Hyponatremia = 3 C’s - Confusion, Convulsions, and Coma

71
Q

A238: What are the main side effects of TCAs? (M)

A

Toxic in overdose, Cardiotoxicity: QT and arrhythmias, hypertension, heart block, Antimuscarinic SE, Seizures, MT: TCAS

72
Q

A239: What are the main problems with MAOI’s? S

A

Dangers of dietary and drug interactions

73
Q

A240: What drug treatment can be used to treat mild depression and what problems are associated with this drug? G

A

St. John’s Wort, Main problems: No standard dose as content varies between each brand, Enzyme inducer so lots of interactions

74
Q

A241: How long should people continue taking antidepressants? R

A

Patients with a history of recurrent depression: maintenance treatment 2 years, Take for a further 6 months (12 months for the elderly) after remission, Generalized anxiety: 12 months

CNS November 23 (7 decks)

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