Diseases and Conditions Flashcards
Osteoporosis management
- aims of treatment (1)
- classes of drugs (4)
- main or serious side effects for each
Aim: reduce risk of fragility fracture
Treatment:
. Calcium salts + Vit D (Colecalciferol)
- main ADR: hypercalcaemia (arrhythmias)
. Bisphophenates
- Serious ADR: atypical femoral fx, jaw osteonecrosis, EAM osteonecrosis
- other adv effects: oesophageal abnormalities, hypocalcaemia (spasms, cramping, seizures etc)
. (HRT)
- Serious ADR: inc. risk of thromboembolism/DVT
Diabetes I and II
- insulin-dependant:
routes (1), types of drugs (3) (and names), sources of drugs (3), particular characteristic (1) of these drugs that make insulin better suited for these patients; - Non insulin-dependant:
routes (1), types of drugs (5) (and names), side effects, tolerance/contra-indications, interactions, risks
. Insulin-dependant (most DM-I): Insulin injections (cannot be oral) - Short, Intermediate and Long acting
Insulin produced from Human (biosynthetic - E. Coli, Yeast - has altered DNA to change absorption); used to come from bovine and porcine sources
. Non-insulin-dependant (most DM-II): oral anti-diabetics
Lifestyle changes (diet, weight loss, exercise etc)
Oral antidiabetics require functioning beta cells
- Biguanides (Metformin - drug of choice)
- Sulphenylureas
- Glitazones (Pioglitazone - slow onset… months/year)
- Gliptins (Sita-, Saxa-, Vilda-, Lina-, Alo-)
- Acarbose (along with other antidiabetics, eg. metformin) delays digestion + absorption of starches
Biguanides: Metformin - (no weight gain -> weight loss);
. side effects: fewer hypo events (hypoglycaemia very rare); GIT disturbances; may cause lactic acidosis, esp. with patients with renal impairment - should not be taken, even if mild renal impairment
Sulphenalureas: Gli-/-(z)ide (Gliclazide, Glimepiride, Glipizide, Tolbutamine)
. side effects: hypoglycaemia (if too high dose), weight gain (inc. appetite), GI disturbances, skin allergies/rashes
(rarely: bone marrow damage)
. Interactions causing hypoglycaemia: alcohol, other antidiabetic drugs, some antibiotics and antifungals
. Other drugs may cause a decrease in effect
Glitazones risks: bone Fx, HF and bladder CA
side effects: weight gain, fluid retention
Glitpins side effects: GIT, rashes, infections, liver disease, back pain, joint pain
Risks of hypoglycaemia (less than sulphenalureas)
Acarbose side effects: GI disturbance
OA
- 1st line treatment for pain relief
. paracetamol 1st line (pain relief)
. NSAIDs if severe and ass. w. inflammation
inflammatory arthritides
- main drug classes used, and actions (3)
- names of drugs of the 3rd class
. NSAIDs (pain relief)
. steroids (inflammation control)
. Antibody therapies and other to suppress disease process (allow reduction of NSAIDs and steroids)
Examples:
. hydroxychloroquine (anti-malarial), Gold salts, penicillamine, sulphasalazine, methotrexate
Constipation
- 2 main aims of treatment, order of treatment
- drug families (4) (names)
- side effects
1- Diet, Fluid intake
2- Laxatives
. Pushers (stimulate motility) - Bulk Laxatives (husk) and Stimulant laxatives (Senna, Bisacodyl) ADRs: abd. cramps
. Softeners - Osmotic Laxatives (Lactulose; Docusate) ADRs (Lactulose): diarrhoea, teeth rotting, abd cramps, weight gain
Vomiting, Nausea
- types of neurotransmitters involved (4) and action
- types of drugs (3) (and names and main usage)
-
Antiemetics - receptor antagonists
Range of neurotransmitters involved
Histamine 1, Dopamine, 5HT3 (Serotonin), Ach
Examples:
H1RA: Cyclizine (motion sickness) - ADRs: drowsiness
D2RA: Domperidone, Metoclopramide - ADRs: dystonia, gynaecomastia, menstrual changes
5HT3: Ondansetron (used with cytotoxic drugs)
GORD, Dyspepsia, Ulceration
- types of drugs (3) (and names)
- causes (3 main)
- testing and treatments
- chances of recurrence
- side effects
1- Antacids (alkalis) - early stage GORD, Dyspepsia (Gaviscon)
2- PPIs (Omeprazole, Lanzoprazole… -zole)
3- H2RA (Ranitidine, Cimetidine, Famotidine, Nizatidine… -tidine)
can be due to long term use of NSAIDs and/or H. Pylori bacterial infection; alcohol/smoking/diet
- test for H. Pylori (breathing tests, faeces sample)
- eradicate H. Pylori (-> 2 AB + PPIs)
- Lifestyle: diet, stop smoking/alcohol
- relapse is common
- Bleeding = red flag
Side effects:
- antacids: burping (belching) due to CO2
- PPIs: GI disturbances, h/a, skin rash
- H2RAs: GI disturbances (diarrhoea), dizz, h/a
Pain relief
- types of drugs (4) and 1st line of use for each
- names
- side effects and how we mitigate them
- risks
Paracetamol (rare side effects) 1st line for single dose
NSAIDs
. Non-selective, incl. Aspirin (-> GIT Tract, bruising, bleeding) - must be taken with PPIs; e.g. ibuprofen, naproxen, diclofenac
. Selective COX-2 (- > no side effects, but inc. risk of MI) - ‘coxibs’ e.g. Celecoxib, Etoricoxib
Costicosteroids (-> Cushing’s, osteoporosis, diabetes)
. e.g. hydrocortisone, prednisolone (long-term disease supression), dexamethasone, beclomethasone (asthma)
Opioids (-> major adv effects: tolerance, dependence, respiratory depression, sedation and euphoria)
. e.g. morphine, diamorphine, codeine, pethidine, tramadol, fentanyl
Asthma
(and COPD, may co-exist)
- physiological changes (acute asthma, COPD)
- symptoms for each condition
- aim of treatment for each condition (drugs, non-drugs)
- drug types (3; symptoms and prevention) and used for…
(acute exacerbation, reduce inflammation, reduce mucus secretions)
- routes
- methods of diagnosis and monitoring for both conditions
- side effects
- Asthma management / therapies and dosage
Physiological changes:
. Asthma: inflammatory - several triggers (stress, allergens, exertion etc) - reversible airflow obstruction
. COPD: fixed, irreversible airflow obstruction (acute exacerbation symptoms may be reversible => bronchodilators) - exercise related stress (breathlessness) - main cause is smoking.
Diagnosis, Monitoring:
. Asthma - peak flow measurments; regular reviews
. COPD - Lung function tests
Goals:
. Asthma: control inflammation to reduce attacks; symptoms; treat attacks
. COPD: prevent further lung decline; control symptoms and attacks; smoking cessation, lung rehab, vaccination
Symptoms:
. Acute asthma attack: wheezing, coughing - inflammatory
. COPD: cough, breathlessness, exacerbations
Asthma Method:
1- Relievers: Blue inhaler (acute) beta2 adrenoreceptor AGONISTS (SABAs, LABAs)
2- Preventers: Brown inhaler (steroids - long-term to reduce airway inflammation and reduce exacerbations)
Other: acute + chronic asthma, and COPD
3- Anticholinergics (inhibit ParaSymp = reduce excessive bronchial secretions) - COPD
COPD:
1- acute symptoms (beta2 recep agonists)
2- prevention of exacerbations (steroids)
3- reduce mucus production: mucolytics, anticholinergics
4- other drugs: Roflumilast (target cells and mediators believed to be important in COPD)
Step-wise management therapy (from diagnosis to graded dosage of corticosteroid therapy)
1- Acute Asthma symptoms control (and COPD reversible)
. Beta2 adrenoreceptor agonists => bronchodilation, vasodilation (+/- inc. heart rate, visceral smooth muscle relaxation, glycogenolysis, muscle tremor)
. side effects: hypokalaemia (Na/K pump)
. Types:
- SABA (short acting beta agonists): salbutamol, terbutaline, fenoterol - for infants, attacks
- LABA (long acting beta agonists): salmeterol, formoterol - for maintenance (additional)
. By inhaled route (usually)
2- Corticosteroids - predominantly for asthma (COPD: if coexists and exacerbations); most important effect in asthma is inflammatory response reaction to allergens
E.g. Beclometasone d., Budesonide, Ciclesonide, Fluticasone p. , Mometasome f.
Prevention: inhaled
Acute reaction: oral
side effects: rare; oral thrush (candidiasis)
3- Anticholinergics: Ipratropium bromide, Tiotropium
side effects: constipation, dry mouth, cough, GI dist, h/a, sinusitis
Blood pressure (hypertension)
- physiology aims
- targeted organs (3) and drug families (p2,h2,k3)
- side effects of BB and ACE-I
due to increased peripheral resistance, increased blood volume (water/electrolytes) and increased heart activity
. Smooth muscles:
- Alpha blockers (vasodilation)
- Ca channel blockers (amlodipine) incl. coronary vessels
. Heart (Myocardium):
- Beta blockers (slows HR and contraction force)
- Ca channel blockers (varepamil, diltiazem)
. Kidneys:
- ACE inhibitors (decrease sodium reabsorption) (1st line when < 55’s) (e.g. Captopril, Ramipril, Enalapril etc)
- Diuretics (decrease fluid retention) e.g. Amiloride, Spironolactone
- ARBs: vasodilation
ACE inhibitors side effects: - first dose hypotension, postural hypotension - renal dysfunction - hyperkalaemia . COUGH (not present with ARBs)
Beta-blockers (beta2 - peripheral) side effects:
- bronchi dilatation (C.I. in asthma!)
- Constipation
- Cold extremities
Clotting/Thromboembolism/DVT
- classes, names of drugs (6); antidotes
- other uses
- main drug: side effects (3), interactions (2), contra-indications (7)
Blood thinners, anticoagulants
1- Heparin (hospitals) - IV or subcutaneous
2- Vit K inhibitors: Warfarin (community) - requires INR checks (levels must be between 2 and 3); (antidote: inc. Vit K)
3- newer: Factor Xa Inhibitors: Rivaroxaban, Apixaban (no need of INR monitoring) (Community) (no antidotes)
4- Aspirin: non-selective COX inhibitor - CVD prevention
5- Clopidogrel - CVD prevention
6- newer: Thrombin inhibitors: Dabigatran (antidote available)
Other uses: Warfarin: Atrial Fibrillations (risks of stroke)
Warfarin interactions: multiple
- diet rich in Vit K (green leafy vegetables)
- alcohol
Warfarin side effects: bruising, bleeding, blood too thin
Warfarin C.I.:
- pregnancy (change to heparin if planning to be pregnant)
- uncorrected or risks of major bleeding (ulcers, aneurysms etc)
- recent surgery
- recent stroke
- severe renal impairment
- severe liver impairment
- allergy/hypersensitivity to Warfarin
Heparin side effects: osteoporosis with long-term use
Bacterial infections
- prescription considerations:
Likely microbe, Patient’s, The drug
- Common classes (6), (action), names, usages, side effects, interactions
- Cochrane review on sore throat treated with AB
- Anti-microbial resistance
Antibiotics
Prescription considerations:
- The likely microbe to treat:
. culture, epidemiology, gram (+, -)
- The patient:
. ALLERGIES
. Females: PREGNANCY, breastfeeding, taking ORAL PILL
. Kidney, Liver impairment
. etc
- Antibiotic:
. Dose (age, weight, infection, severity, hep/renal function)
. Route (severity, access - e.g. paraenteral if vomiting)
. Duration (microbe and response)
e.g.: some UTI’s may need only 1 dose
e.g.: TB and osteomyelitis: need prolonged (months)
1- Beta-Lactams (-cillin)
. Oral: Penicillin, Amoxicillin, Ampicillin, Flucloxacillin
. IV/IM: Benzylpenicillin
. used for: respiratory and skin infections, incl. sepsis and meningitis, and h. pylori
. bacteria response: beta-lactamase inhibit beta-lactam
So need to prescribe clavulanic acid to fight back, with Amoxicillin in Co-Amoxiclav
. Side effects:
- Allergies: 10%
- Diarrhoeas: frequent
- Anaphylaxis: 0.05%
. Interactions:
- Oral Contraceptive: dec. contraceptive effect
- Gastric activity: dec. absorption of AB, of other drugs
“False allergy” (gastric discomfort?)
2- Cephalosporins (Cef-)
. 2nd/3rd gen: cefotaxime, ceftriaxone (meningitis)
. broad spectrum, similar to penicillin
. used for: septicaemia, pneumonia, meningitis, biliary-tract infections, peritonitis, UTIs… (i.e. internal, visceral, systemic)
. side effects: ALLERGIES (m/c); 0.5-6.5% of patients allergic to penicillin will be allergic to cephalosporins
3- Macrolides (-mycin)
Act on bacterial ribosomes
!!! Useful on patients with Allergy to Penicillin!
- erythromycin, clarithromycin, azithromycin
4- Metronidazole
Disrupt DNA; Anaerobic, Protozoa
. Used for: H. Pylori eradication, giardiasis, leg ulcers, bowel infections… (i.e. ulcerations and GIT)
. Interactions: Alcohol -> make you feel very ill: severe flushing, h/a, dizziness, nausea and vomiting, breathlessness, palpitations - avoid Alcohol for 48 hours!
5- Tetracyclines => Acne!
Bacterial ribosomes
. Doxycycline: also for gums, and anti-malarial
. C.I.: children < age 8
. side effects: bone and teeth discolouration
6- Chloramphenicol
. Broad spectrum
. Used in life-threatening infections
. Common usage: eye drops in conjuctivitis
. Rarely used orally (d/t bone marrow toxicity)
side effects (oral): anaemia (reversible); bone marrow damage (irreversible unless transplant)
Cochrane review:
. Sore throat - using AB only improves symptoms by 16 hours; NNTT Tonsillar abscess: 3000; Otitis Media: 200
=> judging risks vs. benefits
Anti-microbial resistance:
. Now also in community (used to be hospital only - MRSA); E. Coli
. Linked to overuse and inappropriate use
- not finishing course of AB
- overuse in livestock and fishing industries
- poor hygiene and sanitation
- lack of new AB being developped
Cholesterol
- most common drug families (and names)
- aims of treatment (outcome on LDL and CVD)
- side effects: classic, general and serious
- Interactions
- other drug types (2nd line; 2 types)
Statins
. Aim: reduce LDL by 40% (dose varies)
. 1st line (other: Fibrates; bile acid sequestrant resins)
. Classic side effects: myalgia, muscle cramp
Rhabdomyolysis, Myositis - rare, m/l to occur within first 3 months
. other side effects: h/a, GIT disturbances
. Interactions: other lipid lowering drugs; grapefruit
Common names:
atorvastatin
fluvastatin
lovastatin
pravastatin
pitavastatin
simvastatin
rosuvastatin
Allergies and Hypersensitivities
- drugs and routes
- side effects
Corticosteroids (oral, topical/inhalers)
Risk: addisionian crisis if withdrawn suddenly
Other risks: Cushing’s, osteoporosis, diabetes
Addison’s disease
(primary adrenals failure)
- drug family used (1)
- risks and side effects
Corticosteroids
Risk: addisionian crisis if withdrawn suddenly
Other risks: Cushing’s, osteoporosis, diabetes
Gout’s 2 types of drugs (and actions)
NSAID: Allopurinol: Inhibit crystallisation within joints
Probenecid: increase excretion of uric acid
Angina (cardiac chest pain)
- aims of treatment (2)
- target organs (2) and drug families (and names)
- side effects of main drug families
due to decreased coronary arteries efficiency and excessive demand for oxygen from heart
. Vasodilation (increase flow in coronary arteries)
Nitrates (acute: sulingual GTN spray) / (chronic: isosorbide dinitrate or mononitrate)
Ca channel blockers (Amlodipine, incl. coronary vessels)
. Myocardium (decrease oxygen demand) Beta blockers (atenolol (beta1), propranolol (non-spec)) Ca channel blockers (Verapamil, Diltiazem)
Nitrates side effects:
- headache (commonest)
- Post. Hypotension, Dizziness
- Tachycardia
Ca channel blockers side effects:
- Verapimil, Diltiazem (heart) - avoid in HF/Heart Block
- Bradycardia
- hypotension, dizziness
- headache, GI
- oedema
- palpitations
Beta-blockers (beta2 - peripheral) side effects:
- bronchi dilatation (C.I. in asthma!)
- Constipation
- Cold extremities
Beta-blockers (beta1 - cardiac) side effects:
- Bradycardia (avoid in heart block, heart failure)
- Heart failure
- hypotension
- hypoglycaemia (caution in Diabetes)
Heart failure - aims of treatment - target organs (3) and medications => kidneys: classes (4) and drug names => peripheral circulation: classes (4) => Heart: drug name (1) - side effects of main medications
causes oedema -> aim is to reduce peripheral resistance and oedema, and increase heart contractions
. Decrease oedema (kidneys):
Diuretics ((k-loss): thiazides/bendrofluazide and Loop: Fremuside; (k-spared): Amiloride, Spronolactone)
ACE inhibitors (e.g. Captopril, Ramipril, Enalapril etc)
. Vasodilation, smooth muscles relaxation:
Alfa and Beta blockers
Nitrates (GTN spray, dinitrates, mononitrates)
ACE Inhibitors are vasodilators (1st line < 55’s)
. Strengthen heart contraction
Digoxin
Side effects of Non-K-Sparing Diuretics:
Loop»_space; Thiazides
- serious: : hypokalaemia (muscle weakness, arrhythmia);
- Thiazides: erectile dysfunction and gout (decrease uric acid excretion)
- other, common: urinary disorders (inc. freq, urgency, incontinence) and sleep disruption (best taken in the morning for most)
Side effects of Digoxin (Na/k pump inhibition):
- serious: narrow TW - toxicity; electolyte imbalance in renal failure;
- other: GI, Arrythmias, dizziness, yellow vision (xanthopsia), blurred vision
Arrythmias
(AF, Heart block, Bradycardia, SV Tachycardia, VF)
- physiological aims (2)
- medications (2 specific)
- other common medications (2)
- side effects of main medications - serious, general
Targets: Pacemaker and Refractory period (calcium plateau)
. Amiodarone (prevention)
. Digoxin (heart rate control, slows AV conduction)
Also commonly prescribed to reduce heart activity:
. Beta blockers (atenolol, bisoprolol and metoprolol etc)
. Ca channel blockers (verapamil and diltiazem)
Side effects digoxin (Na/k pump):
- serious: narrow TW - toxicity; electolyte imbalance in renal failure;
- other: GI, Arrythmias, dizziness, yellow vision (xanthopsia), blurred vision
Anxiety
- 3 classes of drugs, and names/side effects
- what should the main class be avoided in elderly?
-
. Beta blockers (also for tremors)
. Benzodiazepines
Diazepam, Lorazepam, Nitrazepam, Temazepam, Midalozam - tolerance and dependency; drowsiness
- Avoid in elderly d/t risk of falls
. Anti-depressants
Acute Diarrhoea
- methods (1,2,3), names of drugs and side effects
1- rehydration: isotonic solutions of NaCl + glucose
2- anti-motility agents: Loperamide (ADRs: drowsiness, nausea)
3- If required, Antibiotics
Inflammatory Bowel Disease
- Crohn’s (CD), Ulcerative Colitis (UC)
- methods: acute symptom relief, remission, immunosupressant… classes and names, side effects
1- Acute: glucocorticoids (paraenteral, oral)
2- UC acute attacks and maintenance of remission: Aminosalicylates (Mesalazine);
3- Immunosuppressants (Ciclosporin, azathioprin) - ADRs: bone marrow -> anaemia, infections, bleeding
Contraception:
- most to least effective (9 methods at least)
- types (O, P, Comb)
- modes of action (3)
- risks for each (mostly for Prog and Comb)
- prescribing (cautions - 4)
- main serious interactions (2) (and no interactions - 2)
Most to Least effective:
- Vasectomy, Female Sterilisation, Prog IMP, IUDs (coil, hormone)
- Prog Injections
- CHC, POC
- Condoms…
- Fertility awareness methods
Main methods:
- Oestrogen containing:
Comb Oral Pill, Vaginal ring, Transdermal patch
- Progesterone containing:
POP, PO Injectable, PO Implant, Prog releasing IUD
Modes of action:
- oestrogen inhibits release of FSH (neg feedback loop) preventing development of ovarian follicle
- progesterone inhibits release of LH and Ovulation (other actions preventing passage of sperm)
- Combined O+P alter the endometrium to prevent embryo implantation
Risks:
- PO injectable: decreased BMD (Bone Mineral Density)
- CH Pill: DVT, PE
Prescription:
- PO Injectable (risk of bone loss): under 18: ok when all other options considered; switch method at 50 (recommended); review prescription every 2 years
- CHC: assess risk for DVT/PE (very small risk)
- drug interactions: risk of unwanted pregnancy (esp. antibiotics and antiepileptic)
- If taking teratogenic drugs: minimise risks of pregnancy (e.g. methotrexate for AutoImmune Ds, some antiepileptics, retinoids for acne) both during treatment and some time after; pregnancy prevention plan.
Interactions:
. Any drug causing diarrhoea/vomiting (affect absorption) - many drugs may have this side effect
. Any drugs inducing liver enzymes (inc. metab) important examples: certain antibiotics (rifampicin), antiepileptics, OTC St John’s wort (and
(NB: injectable and IUDs: not affected by interactions)
Virus infection
- targets, which viruses, drugs that inhibit them
Principles: some enzymes are virus specific:
. Reverse transcriptase: HIV - drug: Zidovudine
. DNA polymerase: HSV, ZVZ - drug: Aciclovir
Liver disease and impact on drug handling
- the 3 physiological functions impacted, why?
- Things to be cautious about with drugs with LD
- Especially NSAIDs?
- Dec. Metabolism d/t dec. liver enzyme activity)
- Distribution (impaired portal circ, dec. blood proteins)
- Inc. Bioavailability d/t dec. liver enzyme activity
Increased Bioavailability:
. reduced plasma protein-binding => more circulating active drug (increased effect, side effects)
Metabolism decrease:
. decreased FPM => reduced elimination of drugs (increased effect, side effects)
Effects of liver disease:
- increase drugs side effects
- e.g.: NSAIDs => inc. risk of bleeding, fluid overload
(NSAIDS affect prostaglandins (COX-2) which have diuretic effect on kidneys)
- decreased clotting -> need to adjust anticoagulants
- hepatic encephalopathy -> toxicity of CNS
- hepatotoxic drugs -> more damage to liver
NSAIDs: increased risks of bleeding; LD may affect clotting factor synthesis and cause clotting disorders, increasing risk of bleeding even more.
Kidney disease and impact on drug handling
- what is the most important physiological function impacted, why?
- what is important to check when prescribing drugs?
- what other 2 physiological functions may be affected?
- what are the consequences then?
- What with NSAIDs?
- most important effect: reduced elimination of drugs (due to reduced GFR = wee less and filtrates less)
- it is important to check the renal function or to measure the plasma levels of the drugs, and adjust dosage of drugs accordingly.
- Protein-binding, Metabolism (why?…)
- drug effect may be altered (inc. or dec.)
NSAIDs: non-selective COX inhibitors; inhibit prostaglandins, which also have a regulation function in the renal blood flow
=> reduction in renal blood flow reduces renal function and may cause renal tubular necrosis;
=> may also cause fluid retention and hyperkalaemia.
=> avoid in patients with renal impairment; if absolutely needed, use lowest dose for shortest time possible
Ageing
- how is body drug handling affected? (4 points)
- prescribing: things to avoid, be cautious of
- 1st Pass Metabolism (FPM) (dec)
- Distribution (dec)
- Metabolism (dec)
- Elimination (dec)
=> effects (and side effects) of drugs can be increased or decreased
Prescribing drugs:
- avoid polypharmacy
- avoid marginally effective drugs
- review medication regularly
- INTERACTIONS - elderly and NSAIDs (bleeding if on blood thinners)
Pregnancy
- how is body drug handling affected? (X points)
- prescribing: things to avoid, be cautious of
- how the body handles drugs changes during pregnancy (plasma proteins, fluid compartments)
- drugs cross placenta and may affect foetal development
- teratogenesis:
… greatest risk occurs before woman knows she is pregnant
… antiepileptics (phenytoin)
… NSAIDs - 3rd trim - may cause closure of foetal ductus arteriosus in utero (-> persistent pulmonary HT in infants) - may also delay onset of labour and prolong labour
Prescribing:
. All women in age of child bearing age should be considered for the possibility of being pregnant
. BNF best source of information
Epilepsy
- drug family
- prescribing
- risks
- some common names
- interactions
- other drugs used to manage epilepsy symptoms
Antiepileptics
. Aim: seizure free
. drugs: according to type of seizure vs. side effects; multiple drugs may be needed (toxicity increase); require progressive withdrawal
. risks: teratogenic - advise on most effective methods of contraception (Valproate = highest risk, NTD -> Folic Acid! )
. some common drugs:
- Sodium Valproate (1st line - teratogenic - liver)
- Lamotrigine (1st line)
- Carbamazepine (1st line)
- Ethosuximide (1st line)
- Phenytoin (NTW and acute toxic side effects)
. interactions:
with CNS drugs
. Other drugs:
benzodiasepines (antixiety)
Migraine
- aims of treatments (2)
- drug management for each (2, 3)
(primary episodic headache disorder)
- Aims: prevention, acute exacerbations (symptoms)
Acute attacks:
- h/a (analgesics)
- nausea/vomiting (anti-emetics)
- combination preparations
Analgesics: paracetamol, aspirin, NSAIDs, Triptans, (5HT1R Agonists) (sumitriptan)
Antiemetics: metoclopramide, domperidone (promote gastric emptying)
Prevention:
- Beta-Blockers (propranolol, atenolol etc)
(side effects: cold extremities; C.I.: asthma)
- TCAs (amitriptylline)
(side effects: dry mouth, sedation, nausea)
(also used in frequent TTHA)
- Topirimate
(side effects: pins and needles)
TT headache
TCA’s
Medication-overuse headache
Resolves on withdrawal of drug
- h/a likely to get worse (2-10 days) before it improves
- may be ass with nausea, vomiting (anti-emetics)
Cluster headache
- aims of treatments (2)
- drugs that may be prescribed (NB: not primary use)
. Requires specialist management
. Acute symptoms: Triptans or Oxygen Therapy
. Prevention: Verapimil (CaChB), Lithium, Prednisolone
Depression
- Neurotransmitters that may be involved
- drugs effects on NT’s
- The 3 main classes of drugs and names
- natural drugs
- other drugs
- NT’s: dopamine, serotonin, noradrenaline
- Effective drugs decrease alter NT availability and b/d
- drugs that deplete these NT’s can cause depression
SSRI’s (1st line)
. Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Citalopram
- side effects: may increase anxiety at first; Paroxetine: difficulties to withdraw; GI disturbances, h/a, insomnia, agitation; ass w inc risk of bleeding (esp. elder on NSAIDs or anticoagulants)
- similar in effectiveness to TCA’s but better tolerated and safer in overdose (-> 1st line)
TCA’s (block uptake of NA and Ser)
. Amitriptyline, Nortriptylin, Imipramine, clomipramine
(lower dose: neuropathic pain relief, migraine prevention)
- Also block A-adrenoreceptors, Ach Rec, HT Rec and cause sedation => can be useful for agitation and insomnia
- risks: overdose (toxic)
- side effects: palptations, agitation, HT, oedema, dry mouth, constipation, urinary symptoms, sexual dysfunction, mydriasis, glaucoma
Monoamine Reuptake Inhibitors (MAOI)
(block MA oxydase)
. Tranylcypromine, phenelzine, isocarboxazid
. Specialist use - resistant or atypical depression
. risks: toxicity (dangerous)
. most important side effect: allergy crisis due to tyramine-containing food (cheese!) or drugs
Saint John’s wort
Uncertainties on: dosage, prep, persistence, interactions
. interactions: oral pill, anticoagulants, anticonvulsants
Other drugs
. venflaxine, duloxetine (Ser and NA reuptake Inh)
. Flupenthixol
. Vortioxetine (new) sort of SSRI
Bipolar disorder
- main drug
- usage
- risk and important need to monitor
- interactions
- side effects
Lithium (mood stabiliser)
. use: for acute manic episodes
. can be use as adjunctive in depression
. NTW -> fluid/Na balance important (monitoring!)
. Interactions: NSAIDs, Diuretics
. Side effects: tremor, polydipsia/uria, GI dist; thyroid; kidneys
Schizophrenia
- drugs family
- aims (2) of treatment
- drug names (1st and 2nd gen)
- some side effects (think extrapyramidal)
Antipsychotics
. Aims: to improve cognitive and social functioning, and reduce suffering
. 1st gen: chlorpromazine, haloperidol (effect on Dopamine Receptors -> BG, parkisonism)
. 2nd gen: olanzapine (wider range, inc. effect on negative symptoms)
side effects:
- parkinsonism: tremor, gait
- dystonia, dyskinesia
- Akathisia (restlessness)
- Tardive dyskinesia (rhythmic, unvol face/mouth/tongue movements); irreversible, fairly common
- reduced BMD
- breast enlargement
- CV
- Hyperglycaemia
- Neuroleptic malignant syndrome (can be fatal)
