CNS Part 5 November 23

Question 1

Question

Answer 1

Answer

Question 2

A242: What should patients do if they’re experiencing suicidal thoughts and behavior while taking antidepressants?

Answer 2

Children, young adults & individuals with a history of suicidal behavior are particularly at risk. Monitor patients for suicidal behavior, self-harm, and hostility, especially at the beginning of treatment or if the dose changes. Report symptoms.

Question 3

A243: What is serotonin syndrome?

Answer 3

Serotonin syndrome is a relatively uncommon adverse drug reaction caused by excessive central and peripheral serotonergic activity.

Question 4

A244: What are the main reasons serotonin syndrome occurs?

Answer 4

Serotonin syndrome can occur when using an SSRI/SNRI along with another drug that raises serotonin levels. It is a rare side effect.

Question 5

A245: What are the main symptoms of serotonin syndrome?

Answer 5

Symptoms include a nervous system out of control with tremors and muscle spasms, autonomic dysfunction with tachycardia, blood pressure changes, diarrhea, hyperthermia, shivering, and sweating, and altered mental state with confusion, mania, and agitation. The drug should be stopped if this happens.

Question 6

A246: What other antidepressants are used to treat depression if the 1st line options don’t work?

Answer 6

Mirtazapine is used if the initial response to SSRI fails. Second-line choices include Lofepramine, moclobemide, reboxetine, with Venlafaxine reserved for more severe cases. MAOIs require specialist supervision. Third-line options include adding another antidepressant class or lithium/antipsychotic.

Question 7

A247: Give examples of sedating TCA’s.

Answer 7

Examples of sedating TCAs include Amitriptyline (for agitated and anxious patients), clomipramine, dosulepin (toxic in overdose), doxepin, mianserin, trazodone (a serotonin uptake inhibitor), and trimipramine.

Question 8

A248: Give examples of less sedating TCA’s.

Answer 8

Less sedating TCAs include Nortriptyline, Imipramine, and Lofepramine.

Question 9

A249: Which patients require sedating and less sedating TCA’s?

Answer 9

Sedating TCAs are good for nervous and anxious patients and those who struggle to sleep. Less sedating TCAs are suitable for withdrawn and apathetic patients.

Question 10

A250: What are the main contraindications of TCAs?

Answer 10

Contraindications include manic phase bipolar disorder, arrhythmias, heart block, immediate recovery period after MI, and mainly cardiovascular-related issues.

Question 11

A251: What are the cautions with TCA’s?

Answer 11

Cautions include cardiovascular disease, diabetes, chronic constipation, epilepsy, a history of bipolar disorder and psychosis, hyperthyroidism (due to the risk of arrhythmia), glaucoma, urinary retention, and caution in elderly patients who are more susceptible to side effects.

Question 12

A252: Are TCA’s safe in pregnancy and breastfeeding?

Answer 12

In pregnancy, TCAs should only be used if the benefits outweigh the risks. Breastfeeding is generally considered safe.

Question 13

A253: What are the main side effects of TCA’s?

Answer 13

Main side effects include toxicity in overdose, cardiotoxicity (arrhythmias, QT prolongation, heart block, and hypertension), anticholinergic effects (dry mouth, constipation, blurred vision, confusion), seizures, and memory issues.

Question 14

A254: What are the main anticholinergic/antimuscarinic side effects of TCAs?

Answer 14

Anticholinergic/antimuscarinic side effects of TCAs include anorexia, blurry vision, constipation, confusion, dry mouth, and static urine.

Question 15

A255: What are the signs of TCA overdose?

Answer 15

Signs of TCA overdose include hyponatremia, cardiotoxicity, antimuscarinic effects (dry mouth, coma, hypotension, convulsions, arrhythmia, dilated pupils, urinary retention).

Question 16

A256: What’s the main side effect of lofepramine?

Answer 16

The main side effect of lofepramine is liver toxicity.

Question 17

A257: What conditions can TCA’s aggravate?

Answer 17

TCA’s can aggravate mania, cardiovascular disease, bipolar disorder, epilepsy, diabetes, chronic constipation, and eye conditions like angle-closure glaucoma.

Question 18

A258: What are the main drug interactions associated with TCAs?

Answer 18

Drug interactions include serotonin syndrome with other antidepressants, triptans, and tramadol, arrhythmias with lithium, beta-blockers, antipsychotics, amiodarone, macrolides, and quinolones, QT prolongation with various drugs, hyponatremia with diuretics and carbamazepine, hypotension with blood pressure drugs, antimuscarinic effects with antipsychotics and antihistamines, and increased risk of severe toxicity when given with MAOIs.

Question 19

A259: Which MAOI’s cause hepatotoxicity?

Answer 19

Isocarboxazid and phenelzine can cause hepatotoxicity.

Question 20

A260: Which MAOI has the greatest risk of hypertensive crisis?

Answer 20

Tranylcypromine has the greatest risk of hypertensive crisis.

Question 21

A261: Why are MAOI’s less commonly used in practice?

Answer 21

MAOIs are less commonly used due to their numerous interactions with foods rich in tyramine and other medications.

Question 22

A262: Which foods need to be avoided when taking MAOIs and why?

Answer 22

Tyramine-rich foods need to be avoided because they can trigger the release of noradrenaline, which increases blood pressure and can cause throbbing headaches. Examples include mature cheese, pickled herring, broad bean pods, meat or yeast extract, and fermented soybean extract.

Question 23

A263: Which foods are rich in tyramine?

Answer 23

Tyramine-rich foods include mature cheese, salami, pickled herring, meat or yeast extract, fermented soybean extract (e.g., Bovril, Oxo, Marmite), and some beers, lagers, or wines.

Question 24

A264: Are MAOI’s safe in pregnancy and breastfeeding?

Answer 24

In pregnancy, MAOIs should be used only if the benefits outweigh the risks. Breastfeeding should be avoided or used with caution depending on the specific MAOI.

Question 25

A265: What are the main side effects of MAOI’s?

Answer 25

Side effects of MAOIs include blood disorders, nausea and vomiting, constipation, headache, suicidal behavior, and insomnia.

Question 26

A266: When should MAOI’s be avoided?

Answer 26

MAOIs should be avoided in acute porphyrias, blood disorders, cardiovascular disease, diabetes, the elderly, epilepsy, and in cases of severe hypertensive reactions to certain drugs and foods. Abrupt withdrawal should also be avoided.

Question 27

A267: Can MAOI’s be stopped abruptly, if not, what symptoms occur on withdrawal?

Answer 27

MAOIs should be avoided. Stopping abruptly can lead to symptoms such as agitation, irritability, ataxia, movement disorders, insomnia, drowsiness, vivid dreams, cognitive impairment, slowed speech, hallucinations, and paranoid delusions.

Question 28

A268: What are the main drug interactions involved with MAOI’s?

Answer 28

MAOI interactions include hypertensive crisis with tyramine-rich foods, adrenaline, sympathomimetics, hypotension with blood pressure tablets, alcohol, and SGLT2 inhibitors, serotonin syndrome with other antidepressants, CNS excitation with opiates, and increased risk of severe toxicity when given with MAOIs, so they should be avoided for 2 weeks after stopping MAOIs.

Question 29

A269: What is the patient and carer advice with MAOI’s?

Answer 29

Patients on MAOIs should avoid alcohol completely, eat fresh foods, avoid tyramine-rich foods, be cautious with driving or using tools when drowsy, and learn about potential interactions.

Question 30

A270: What’s the best MAOI to use if you had to choose and why?

Answer 30

Moclobemide is considered the best MAOI because it has fewer tyramine effects, but tyramine-rich foods should still be avoided.

Question 31

A271: Draw a diagram showing how long it takes to switch from one antidepressant to another.

Answer 31

[Diagram not included in text]

Question 32

A272: Which SSRI is the only one that can be given to kids and from what age?

Answer 32

Fluoxetine can be given to children aged 5 and above.

Question 33

A273: Which SSRI is the safest for patients with stable angina or a previous MI?

Answer 33

Sertraline is considered the safest for patients with stable angina or a previous MI.

Question 34

A274: What are the main contraindications for SSRIs?

Answer 34

Contraindications include poorly controlled epilepsy (discontinue if convulsion occurs) and manic phase bipolar disorder.

Question 35

A275: Are SSRI’s safe in pregnancy and breastfeeding?

Answer 35

In pregnancy, SSRI use should be considered carefully, and the risks should be weighed against the benefits. In breastfeeding, some SSRIs are safe, while others require caution or avoidance.

Question 36

A276: What are the main cautions with SSRI’s?

Answer 36

Cautions include cardiovascular disease, epilepsy (stop treatment if seizures occur), diabetes, bleeding disorders, a history of mania, angle glaucoma, and caution in elderly patients.

Question 37

A277: What are the main withdrawal symptoms of SSRI’s, and which one has the highest risk of withdrawal?

Answer 37

Withdrawal symptoms can include headache, anxiety, sweating, flu-like symptoms, tinnitus, and sleep disturbances. Paroxetine is known for having a higher risk of withdrawal symptoms.

Question 38

A278: What is the MHRA/CHM warning with SSRIs?

Answer 38

There is a small risk of postpartum hemorrhage when SSRIs are used in the month before delivery. SSRIs increase the risk of bleeding due to their effects on platelet function.

Question 39

A279: What are the main side effects of SSRI’s?

Answer 39

Main side effects of SSRI’s include anxiety, palpitations, arrhythmias, confusion, drowsiness, QT interval prolongation, dry mouth, constipation, skin reactions, nausea, and hyponatremia.

Question 40

A280: What are the important drug interactions to watch out for when taking SSRI’s?

Answer 40

Important drug interactions include bleeding with antiplatelets, anticoagulants, and NSAIDs, hyponatremia with diuretics, serotonin syndrome with other serotonergic drugs, and interactions with various medications leading to QT prolongation.

Question 41

A281: What are the main uses of antipsychotics?

Answer 41

Antipsychotics are used to treat conditions like schizophrenia, toxic delirium, mania, agitated depression, and severe anxiety (short-term use).

Question 42

A282: What are the 2 main aims of treating psychosis?

Answer 42

The two main aims of treating psychosis are to alleviate the suffering of the patient and their caregiver and to improve social and cognitive functioning.

Question 43

A283: If antipsychotics are used for anxiety, how long are they used for?

Answer 43

Antipsychotics are used for severe or difficult-to-treat anxiety, but they are typically used for the short term.

Question 44

A284: What are the positive and negative symptoms of schizophrenia?

Answer 44

Positive symptoms of schizophrenia include hallucinations, thought disorders, and delusions, while negative symptoms include apathy and social withdrawal.

Question 45

A285: Give examples of 1st and 2nd generation antipsychotics and what is the difference?

Answer 45

Examples of 1st generation antipsychotics include drugs ending in “azine” or “ol,” while 2nd generation antipsychotics end in “apine” or “one.” The key difference is that 1st generation antipsychotics have more extrapyramidal side effects (EPSE) compared to 2nd generation, which are also better at treating negative symptoms.

Question 46

A286: Which phenothiazine antipsychotics are in group 1, 2, and 3, and what’s the difference between each?

Answer 46

Group 1 includes chlorpromazine, levomepromazine, promazine, pericyazine, pipotiazine, and prochlorperazine. Group 2 includes trifluoperazine, fluphenazine, and perphenazine. Group 3 includes those with the least sedation (e.g., least EPSE).

Question 47

A287: If prescribing antipsychotics for the elderly, what must be considered?

Answer 47

When prescribing antipsychotics for the elderly, the risk versus benefit should be carefully evaluated. In dementia, there’s a small increased risk of mortality, stroke, or transient ischemic attack. Elderly patients are susceptible to postural hypotension. The lowest effective dose should be used for the shortest period of time, with regular reviews.

Question 48

A288: What are EP side effects?

Answer 48

Extrapyramidal (EP) side effects of antipsychotics include hyperprolactinemia, Parkinson’s-like symptoms (tremor), acute dystonia (involuntary muscle contractions), akathisia (restlessness), tardive dyskinesia (irreversible locked jaw), weight gain, hyperlipidemia, and hyperglycemia.

Question 49

A289: With which group of drugs are patients more likely to expect EP side effects?

Answer 49

Patients are more likely to experience EP side effects with phenothiazine group 3 drugs, which include those ending in “perazine” and “phenazine.”

Question 50

A290: What needs to be monitored when taking antipsychotics and how often?

Answer 50

Monitoring includes FBC, urea, electrolytes, liver function initially and then annually, blood lipids, weight, fasting blood glucose, ECG, blood pressure, prolactin levels, and physical health assessments at least once a year.

Question 51

A291: Create a table explaining which antipsychotic to take to avoid certain side effects.

Answer 51

[Table not included in text]

Question 52

A292: What’s the main patient and carer advice given to patients on antipsychotics?

Answer 52

Patients on antipsychotics should avoid alcohol, be cautious with driving or using tools when drowsy, avoid sunlight exposure at higher doses, and maintain adequate fluid intake.

Question 53

A293: Which antipsychotic is given last line when all others have failed?

Answer 53

Clozapine is given as a last-line treatment when other antipsychotics have failed.

Question 54

A294: What is the MHRA warning around clozapine?

Answer 54

The MHRA warning for clozapine includes the risk of intestinal obstruction, faecal impaction, paralytic ileus, and the need to seek medical advice if constipation develops. Clozapine should not be combined with other antipsychotics, and there is a risk of agranulocytosis.

Question 55

A295: What are the contraindications for clozapine?

Answer 55

Contraindications for clozapine include alcohol intoxication, bone marrow disorders, coma, drug intoxication, a history of agranulocytosis, circulatory collapse, neutropenia, paralytic ileus, severe cardiac disorders, severe CNS depression, and uncontrolled epilepsy.

Question 56

A296: What are the monitoring requirements of clozapine?

Answer 56

Monitoring requirements for clozapine include regular monitoring of prolactin levels, physical health and cardiovascular assessments, frequent monitoring of complete blood counts (CBC) and white blood cell counts during the initial period, and monitoring of clozapine concentrations in certain clinical conditions.

Question 57

A297: What is the patient and carer advice given to patients on clozapine?

Answer 57

Patients on clozapine should seek medical advice if they experience constipation, avoid driving or using tools when drowsy, inform their GP if they are smokers, avoid direct sunlight with higher doses, abstain from alcohol, and learn how to use the medication correctly.

Question 58

A298: Why are antipsychotics given as depot injections sometimes, and what are the main problems with depot injections?

Answer 58

Depot injections are used for maintenance therapy when patients cannot comply with oral treatment. They may have more extrapyramidal side effects (EPSE) than oral preparations. Depot injections like zuclopenthixol can help prevent relapse, while flupentixol is used for agitated and aggressive patients.

Question 59

A299: What is neuroleptic malignant syndrome?

Answer 59

Neuroleptic malignant syndrome is a rare but fatal side effect of all antipsychotic drugs. It is characterized by hyperthermia, fluctuating consciousness, muscle rigidity, and autonomic dysfunction with fever, tachycardia, labile blood pressure, and sweating. It requires discontinuation of the antipsychotic and treatment with bromocriptine and dantrolene.

Question 60

A300: What is motor neurone disease, and what are the main aims of treating it?

Answer 60

Motor neurone disease is a neurodegenerative condition affecting the brain and spine, leading to muscle weakness, cramps, wasting, stiffness, loss of dexterity, reduced respiration, and cognitive function. The main aims of treating it are to manage symptoms and alleviate suffering.