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HIGH WEIGHTING - Central Nervous System Flashcards

1
Q

DEMENTIA

What are the aims of treatment for dementia?

A
  • Promote independence
  • Maintain function
  • Manage symptoms of dementia
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2
Q

DEMENTIA

(1) What non-drug treatment can be offered in dementia? (2) For which patient group does this apply?

A

(1) Structured group cognitive stimulation programme

(2) All types of mild-moderate dementia

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3
Q

DEMENTIA

What should be considered regarding antimuscarinic drugs in patients with dementia?

A

Anticholinergic burden

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4
Q

DEMENTIA

What should be considered regarding anticholinergic drugs in patients with dementia?

A

Anticholinergic burden

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5
Q

DEMENTIA

Why is anticholinergic burden a point of consideration for dementia patients?

A

Can increase cognitive impairment

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6
Q

DEMENTIA

Name some common drugs with anticholinergic effects.

A
  • Amitriptyline
  • Paroxetine
  • Antihistamines
  • Antipsychotics
  • Urinary antispasmodics
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7
Q

DEMENTIA

Give two examples of urinary antispasmodics.

A
  • Tolterodine
  • Solifenacin
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8
Q

DEMENTIA

What are the first line treatment options for mild-moderate Alzheimer’s disease?

A
  • Donepezil hydrochloride OR
  • Galantamine OR
  • Rivastigmine
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9
Q

DEMENTIA

What is first line treatment for moderate Alzheimer’s disease when acetylcholinesterase inhibitors are contraindicated?

A

Memantine hydrochloride

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10
Q

DEMENTIA

When is memantine hydrochloride considered suitable in treatment of Alzheimer’s disease?

A

(1) Severe Alzheimer’s disease OR

(2) Moderate Alzheimer’s disease
- When acetylcholinesterase inhibitors are contraindicated

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11
Q

DEMENTIA

What is the first line treatment for severe Alzheimer’s disease?

A

Memantine hydrochloride

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12
Q

DEMENTIA

When is donepezil hydrochloride indicated in Alzheimer’s disease?

A

Mild-moderate Alzheimer’s disease

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13
Q

DEMENTIA

When can memantine hydrochloride be used as an additional therapy in Alzheimer’s disease?

A

Patients already receiving acetylcholinesterase inhibitor

IF they develop moderate/ severe Alzheimer’s disease

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14
Q

DEMENTIA

What can be added for an Alzheimer’s patient who is already taking an acetylcholinesterase inhibitor that develops moderate/ severe Alzheimer’s disease?

A

Memantine hydrochloride

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15
Q

DEMENTIA

Should acetyl cholinesterase inhibitors be discontinued in patients with moderate Alzheimer’s disease?

A

No

Can cause substantial worsening in cognitive function

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16
Q

DEMENTIA

What is the first line treatment for mild-moderate dementia with Lewy bodies?

A

Donepezil hydrochloride/ rivastigmine

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17
Q

DEMENTIA

When should galantamine be considered for dementia with Lewy bodies?

A

If BOTH donepezil hydrochloride and rivastigmine are not tolerated

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18
Q

DEMENTIA

What is the first line treatment for severe dementia with Lewy bodies?

A

Donepezil hydrochloride/ rivastigmine

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19
Q

DEMENTIA

When is memantine hydrochloride used in treatment of dementia with Lewy bodies?

A

Alternative when acetylcholinesterase inhibitors are contraindicated or not tolerated

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20
Q

DEMENTIA

When should acetylcholinesterase inhibitors and memantine hydrochloride be considered in treatment of vascular dementia?

A

Suspected co-morbid Alzheimer’s OR

PD dementia OR

Dementia with Lewy bodies

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21
Q

DEMENTIA

Can acetylcholinesterase inhibitors and memantine hydrochloride be used for treatment of frontotemporal dementia?

A

No

Not recommended

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22
Q

DEMENTIA

Can acetylcholinesterase inhibitors and memantine hydrochloride be used for treatment of cognitive impairment caused by multiple sclerosis?

A

No

Not recommended

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23
Q

DEMENTIA

Name some non-cognitive symptoms of dementias.

A
  • Agitation
  • Aggression
  • Distress
  • Psychosis
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24
Q

DEMENTIA

For which symptoms should psychosocial and environmental interventions be used for in dementia treatment?

A
  • Management of pain
  • Management of delirium
  • Reduce distress
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25
Q

DEMENTIA

When are antipsychotic drugs recommended for dementia patients?

A
  • Risk of harming themselves/ others OR
  • Experiencing agitations/ hallucinations/ delusions that are causing severe distress
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26
Q

DEMENTIA

Describe an MHRA warning for dementia regarding antipsychotic drug use.

A

Increased risk of stroke and small increased risk of death when antipsychotic drugs are used in elderly patients with dementia

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27
Q

DEMENTIA

Name some risk factors for cerebrovascular disease?

A
  • Hypertension
  • Atrial Fibrillation
  • Diabetes
  • Smoking
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28
Q

DEMENTIA

How often should antipsychotic drugs be reviewed in patients with dementia?

A

Every 6 weeks

Lowest effective dose should be maintained

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29
Q

DEMENTIA

What effect can antipsychotic drugs have on Parkinson’s disease dementia or dementia with Lewy bodies?

A

Can worsen motor functions

Can cause severe antipsychotic sensitivity reactions

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30
Q

DEMENTIA

(1) What psychological treatments are available for depression and anxiety associated with dementia?

(2) For which patient group does this apply?

A

(1)
- CBT
- Multisensory stimulation
- Relaxation
- Animal-assisted therapies

(2) Mild-moderate depression/ anxiety associated with mild-moderate dementia

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31
Q

DEMENTIA

When should antidepressants be considered for depression/ anxiety associated with dementia?

A

ONLY for pre-existing severe mental health problems

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32
Q

DEMENTIA

How are sleep disturbances managed for patients with dementia?

A

Non-drug approaches

  • Sleep hygiene education
  • Daylight exposure
  • Increased exercise/ activity
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33
Q

DEMENTIA

Name the centrally acting anticholinesterases.

A
  • Donepezil hydrochloride
  • Rivastigmine
  • Galantamine
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34
Q

DEMENTIA

Name an NMDA receptor antagonist associated with treatment of dementias.

A

Memantine hydrochloride

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35
Q

SLEEP DISORDERS

What is an anxiolytic?

A

Sedative

Induces sleep when given at night

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36
Q

SLEEP DISORDERS

What is a hypnotic?

A

Sedative

Sedates during the day

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37
Q

SLEEP DISORDERS

Why should anxiolytics and hypnotics be reserved for short courses?

A

May lead to withdrawal

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38
Q

SLEEP DISORDERS

What are the most common type of hypnotics and anxiolytics used?

A

Benzodiazepines

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39
Q

SLEEP DISORDERS

Briefly describe the mechanism of action of benzodiazepines.

A

Act at benzodiazepine receptors associated with GABA reecotirs

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40
Q

SLEEP DISORDERS

(1) Are barbiturates and meprobamate recommended as hypnotics/ anxiolytics?

(2) Why?

A

(1) No

(2) More side-effects + interactions + more dangerous in overdose

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41
Q

SLEEP DISORDERS

What duration are benzodiazepines indicated for in short-term relief of anxiety that is severe, disabling, or causing unacceptable distress?

A

2-4 weeks ONLY

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42
Q

SLEEP DISORDERS

Should benzodiazepines be used for treatment of short-term mild anxiety?

A

No

Inappropriate use

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43
Q

SLEEP DISORDERS

When should benzodiazepines be used to treat insomnia?

A
  • Severe OR
  • Disabling OR
  • Causing extreme distress
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44
Q

SLEEP DISORDERS

Why should withdrawal of a benzodiazepine be gradual?

A

May produce confusion/ toxic psychosis/ convulsions/ condition resembling delirium tremens

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45
Q

SLEEP DISORDERS

For how long after cessation of treatment can benzodiazepine withdrawal syndrome occur?

A

Up to 3 weeks
- After stopping a long-acting benzodiazepine

Up to 24 hours
- After stopping a short-acting benzodiazepine

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46
Q

SLEEP DISORDERS

How is benzodiazepine withdrawal syndrome characterised?

A
  • Insomnia
  • Anxiety
  • Loss of appetite
  • Loss of bodyweight
  • Tremor
  • Perspiration
  • Tinnitus
  • Perceptual disturbances
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47
Q

SLEEP DISORDERS

What are:
- Insomnia
- Anxiety
- Loss of appetite
- Loss of bodyweight
- Tremor
- Perspiration
- Tinnitus
- Perceptual disturbances

symptoms of?

A

Benzodiazepine withdrawal syndrome

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48
Q

SLEEP DISORDERS

How should benzodiazepine reduction rate be managed?

A

Flexible, at a rate that is tolerable for the patient

Should depend on initial dose/ duration of use/ clinical response

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49
Q

SLEEP DISORDERS

How long is it likely to take a patient who has used benzodiazepines for 2-4 weeks to taper off?

A

2-4 weeks

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50
Q

SLEEP DISORDERS

How long is it likely to take a patient who has used benzodiazepines long-term to taper off?

A

Period of several months or more

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51
Q

SLEEP DISORDERS

What is a suggested protocol for withdrawal of long-term benzodiazepine use?

A

(1) Transfer patient to diazepam, at equivalent daily dose, over about 1 week - preferably taken at night

(2) Reduce diazepam dose by 1-2mg every 2-4 weeks

(3) Reduce diazepam dose further, if necessary in smaller steps (e.g. 500micrograms)

(4) Then stop completely

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52
Q

SLEEP DISORDERS

What is the equivalent dose of 5mg of diazepam in:

(1) Chlordiazepoxide?

(2) Temazepam?

(3) Clobazam?

(4) Clonazepam?

A

(1) 12.5mg

(2) 10mg

(3) 10mg

(4) 250micrograms

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53
Q

SLEEP DISORDERS

The addition of which types of drugs should be AVOIDED when withdrawing from benzodiazepines?

A
  • Beta-blockers
  • Antidepressants
  • Antipsychotics
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54
Q

SLEEP DISORDERS

What type of medication is preferable in treatment of sleep onset insomnia?

A

Short-acting hypnotics

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55
Q

SLEEP DISORDERS

Which type of medication is preferable for treatment of insomnia in elderly patients?

A

Short-acting hypnotics

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56
Q

SLEEP DISORDERS

Which type of medication is preferable for treatment of insomnia when sedation the following day is undesirable?

A

Short-acting hypnotics

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57
Q

SLEEP DISORDERS

Which type of medication is preferable for treatment of sleep maintenance insomnia?

A

Long-acting hypnotics

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58
Q

SLEEP DISORDERS

What may cause transient insomnia?

A
  • Noise
  • Jetlag
  • Shift work
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59
Q

SLEEP DISORDERS

(1) Which type of medication is preferable for treatment of transient insomnia? (2) How many doses should be given?

A

(1) Rapidly-eliminated hypnotic

(2) Only 1-2 doses

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60
Q

SLEEP DISORDERS

What may cause short-term insomnia?

A
  • Emotional problem OR
  • Serious medical illness
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61
Q

SLEEP DISORDERS

What duration of hypnotic should be given for treatment of short-term insomnia?

A

Maximum THREE weeks

(Preferably only ONE week)

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62
Q

SLEEP DISORDERS

What type of medication is preferable for treatment of short-term insomnia?

A

Short-acting hypnotic

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63
Q

SLEEP DISORDERS

What are some common causes of chronic insomnia?

A
  • Anxiety
  • Depression
  • Abuse of drugs/ alcohol
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64
Q

SLEEP DISORDERS

How long does tolerance to hypnotics take to develop?

A

3-14 days of continuous use

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65
Q

SLEEP DISORDERS

What is a major drawback of long-term use of hypnotics?

A

Withdrawal can cause:
- Rebound insomnia
- Withdrawal syndrome

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66
Q

SLEEP DISORDERS

(1) Which hypnotics should be avoided in the elderly? (2) Why?

A

(1)
- Benzodiazepines
- Z-drugs

(2) Elderly are at greater risk of becoming ataxic and confused
- Leads to increased falls/ injury

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67
Q

SLEEP DISORDERS

(1) Which hypnotic is preferable for use in dental patients? (2) Why?

A

(1) Temazepam

(2) Minimise residual effect on following day

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68
Q

SLEEP DISORDERS

Which benzodiazepines used as hypnotics tend to have a cumulative effect due to their prolonged action?

A
  • Nitrazepam
  • Flurazepam
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69
Q

SLEEP DISORDERS

Which benzodiazepines have little-to-no hangover effect?

A
  • Temazepam
  • Loprazolam
  • Lormetazepam
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70
Q

SLEEP DISORDERS

(1) Which treatment is preferable for insomnia that is associated with daytime anxiety? (2) How should this be taken?

A

(1) Long-acting benzodiazepine anxiolytic
- e.g. diazepam

(2) Taken as a single dose at night

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71
Q

SLEEP DISORDERS

Name two Z-drugs.

A
  • Zolpidem
  • Zopiclone
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72
Q

SLEEP DISORDERS

What are some non-benzodiazepine hypnotics that act at the benzodiazepine receptors?

A
  • Zopiclone
  • Zolpidem
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73
Q

SLEEP DISORDERS

Describe the duration of action of the Z-drugs.

A

Short-acting

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74
Q

SLEEP DISORDERS

(1) For which patient group is clomethiazole potentially useful? (2) Why?

A

(1) Elderly

(2) No hangover effect

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75
Q

SLEEP DISORDERS

What is melatonin licensed for?

A
  • Short-term treatment of insomnia in adults >55yrs
  • Short-term treatment of jet-lag in adults
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76
Q

SLEEP DISORDERS

What effect may benzodiazepines have on psychological adjustment in bereavement?

A

May inhibit

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77
Q

SLEEP DISORDERS

Which patient groups have the highest likely dependency to anxiolytic benzodiazepines?

A
  • History of alcohol/ drug abuse OR
  • Marked personality disorders
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78
Q

SLEEP DISORDERS

What effect do beta-blockers have on psychological symptoms?

A

None

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79
Q

SLEEP DISORDERS

What effect do beta-blockers have on non-autonomic symptoms?

A

None

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80
Q

SLEEP DISORDERS

What effect do beta-blockers have on autonomic symptoms?

A

Reduction in symptom severity

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81
Q

SLEEP DISORDERS

Which anxiolytics are indicated for the short-term relief of severe anxiety?

A
  • Diazepam
  • Alprazolam
  • Chlordiazepoxide
  • Clobazam
  • Lorazepam
  • Oxazepam
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82
Q

SLEEP DISORDERS

(1) When are shorter-acting anxiolytics preferable for the short-term relief of severe anxiety? (2) What risk does this present?

A

(1) Hepatic impairment

(2) Increased risk of withdrawal symptoms

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83
Q

SLEEP DISORDERS

What can be used in panic disorders that are resistant to antidepressant therapy?

A

Benzodiazepines

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84
Q

SLEEP DISORDERS

When should IV use of lorazepam/ diazepam be used for the control of panic attacks?

A

When other administration routes have failed

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85
Q

SLEEP DISORDERS

What is the advantage of the IM route of benzodiazepines compared to oral route?

A

None

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86
Q

SLEEP DISORDERS

How long may response to treatment with buspirone take?

A

Up to TWO weeks

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87
Q

SLEEP DISORDERS

Describe the dependence and abuse potential of buspirone.

A

Low

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88
Q

SLEEP DISORDERS

How does meprobamate compare to benzodiazepines, as an anxiolytic?

A

Less effective + more hazardous in overdose

Can induce dependence

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89
Q

SLEEP DISORDERS

When are intermediate-acting barbiturates used for treatment of sleep disturbances?

A

Severe intractable insomnia in patients ALREADY taking barbiturates

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90
Q

SLEEP DISORDERS

In which patient group should barbiturates be avoided?

A

Elderly

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91
Q

SLEEP DISORDERS

Name some intermediate acting barbiturates.

A
  • Amobarbital
  • Butobarbital
  • Secobarbital
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92
Q

SLEEP DISORDERS

What does increased hostility and aggression after barbiturates normally indicate?

A

Intoxication

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93
Q

SLEEP DISORDERS

Name some long-acting benzodiazepines.

A
  • Diazepam
  • Nitrazepam
  • Flurazepam
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94
Q

SLEEP DISORDERS

Name some short-acting benzodiazepines.

A
  • Loprazolam
  • Lormetazepam
  • Temazepam
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95
Q

SLEEP DISORDERS

Which type of benzodiazepines are used for sleep maintenance?

A

Long-acting

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96
Q

SLEEP DISORDERS

Which type of benzodiazepines are used for sleep onset?

A

Short-acting

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97
Q

SLEEP DISORDERS

How is benzodiazepine overdose treated?

A

Flumazenil

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98
Q

SLEEP DISORDERS

Which benzodiazepines have a legal driving limit?

A
  • Clonazepam
  • Oxazepam
  • Lorazepam
  • Diazepam
  • Flunitrazepam
  • Temazepam
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99
Q

Epilepsy

What is the first line treatment for focal seizures?

A
  • Carbamazepine OR lamotrigine
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100
Q

Epilepsy

What is the second line treatment for focal seizures?

A
  • Oxcarbazepine
  • Levetiracetam
  • Sodium valproate
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101
Q

Epilepsy

What are the different types of generalised seizures?

A
  • Tonic clonic
  • Absence
  • Myoclonic
  • Atonic
  • Tonic
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102
Q

Epilepsy

What is the first line treatment for tonic clonic seizures?

A

Sodium valproate

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103
Q

Epilepsy

What is the second line treatment for tonic clonic seizures?

A

Lamotrigine

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104
Q

Epilepsy

What is the first line treatment for absence seizures?

A

Ethosuximide OR sodium valproate

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105
Q

Epilepsy

What is the second line treatment for absence seizures?

A

Lamotrigine

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106
Q

Epilepsy

What is the first line treatment for myoclonic seizures?

A

Sodium valproate

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107
Q

Epilepsy

What is the second line treatment for myoclonic seizures?

A

Topiramate OR levetiracetam (Keppra)

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108
Q

Epilepsy

What is the first line treatment for tonic seizures?

A

Sodium valproate

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109
Q

Epilepsy

What is the second line treatment for tonic seizures?

A

Lamotrigine

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110
Q

Epilepsy

What is the first line treatment for atonic seizures?

A

Sodium valproate

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111
Q

Epilepsy

What is the second line treatment for atonic seizures?

A

Lamotrigine

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112
Q

Epilepsy

For treatment of epilepsy, for which type(s) of generalised seizures is sodium valproate first line treatment?

A
  • Tonic Clonic
  • Tonic
  • Atonic
  • Myoclonic
  • Absence
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113
Q

Epilepsy

For treatment of epilepsy, for which type(s) of generalised seizures is lamotrigine second line treatment?

A
  • Tonic Clonic
  • Tonic
  • Atonic
  • Absence

(All, except myoclonic)

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114
Q

Epilepsy

What is the treatment for status epilepticus seizures lasting longer than 5 minutes?

A
  • IV lorazepam (repeated once after 10 minutes if seizures recur/ fail to respond)

OR

  • IV diazepam
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115
Q

Epilepsy

What is the treatment for status epilepticus, if seizures fail to respond to treatment after 25 minutes?

A
  • Phenytoin
  • Fosphenytoin
  • Phenobarbital
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116
Q

Epilepsy

What is the treatment for status epilepticus, if seizures fail to respond to treatment after 45 minutes?

A
  • Thiopental
  • Midazolam
  • Propofol (anaesthetic)
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117
Q

Epilepsy

What is the treatment of status epilepticus, in the community or where resus is not available?

A
  • Rectal diazepam

OR

  • Buccal midazolam
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118
Q

Epilepsy

Which add-on drug can be used for treatment of status epilepticus if alcohol abuse is suspected?

A

Parenteral thiamine

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119
Q

Epilepsy

What is the add-on treatment of status epilepticus, if pyridoxine deficiency is suspected as the cause?

A

Pyridoxine

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120
Q

Epilepsy

What needs to be done if a driver experiences epilepsy while driving?

A

Stop driving immediately

DVLA must also be informed

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121
Q

Epilepsy

What are the driving rules for a patient with their first unprovoked/ single isolated seizure?

A

May resume provided they have been assessed by a specialist as fit to drive

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122
Q

Epilepsy

What are the driving rules for a patient with established epilepsy for personal vehicles?

A
  • Must be seizure free for one year

OR

  • A pattern of seizures established with no effect on consciousness for one year
  • ALSO:
    ø Must not have a history of unprovoked seizures
    ø Additional criteria applies for large goods/ passenger-carrying
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123
Q

Epilepsy

What must be remembered regarding driving rules for a patient with established epilepsy for driving on large goods vehicles/ passenger-carrying drivers?

A
  • Must be seizure free for one year

OR

  • A pattern of seizures established with no effect on consciousness for one year
  • ALSO:
    ø Must not have a history of unprovoked seizures
    ø Additional criteria applies for large goods/ passenger-carrying
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124
Q

Epilepsy

What are the driving rules for a patient with seizures while asleep?

A

Not permitted to drive for 1 year from date of seizure UNLESS:
- Hx of sleep seizures ONLY while asleep (established over 1 year)
- If previous seizures while awake but shown to only have sleep seizures over the past 3 years

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125
Q

Epilepsy

What are the driving rules for a patient with epilepsy who has had a medication change/ withdrawal?

A
  • Should not drive for at least 6 months after last previous dose
  • IF seizure occurs, license revoked for one year (reinstated after 6 months if treatment resumed AND no further seizures occurred)
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126
Q

Epilepsy

What is the risk vs benefit of epilepsy treatment in pregnancy?

A

Risk of harm to mother and foetus from convulsions outweighs risk of continued treatment

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127
Q

Epilepsy

Why is folic acid given in pregnancy?

A

Reduce risk of neural tube defects in first trimester

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128
Q

Epilepsy

At what stage of pregnancy can neural tube defects occur in the foetus without folic acid supplementation?

A

First trimester

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129
Q

Epilepsy

What injection is given at birth to reduce the risk of neonatal haemorrhage?

A

Vitamin K injection

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130
Q

Epilepsy

Why is a vitamin K injection given at birth?

A

To reduce risk of neonatal haemorrhage

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131
Q

Epilepsy

(1) Who is at most risk from sodium valproate treatment? (2) How is this prevented?

A

(1) Pregnancy/ foetus

(2) Pregnancy Prevention Programme

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132
Q

Epilepsy

What is the risk of using topiramate in pregnancy?

A

Risk of cleft palate development

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133
Q

Epilepsy

Which anti-epileptic medication cause the most risk in treatment of pregnant patients?

A
  • Sodium valproate
  • Topiramate
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134
Q

Epilepsy

What is the breastfeeding advice for patients on epilepsy treatment?

A

Encouraged to breastfeed, on single treatment

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135
Q

Epilepsy

Which anti-epileptics are highly present in breast milk?

A
  • Primidone
  • Ethosuximide
  • Lamotrigine
  • Zonisamide
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136
Q

Epilepsy

Which anti-epileptics have the highest risk of drowsiness in breastfeeding?

A
  • Primidone
  • Phenobarbital
  • Benzodiazepines
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137
Q

Epilepsy

Which anti-epileptics can cause withdrawal effects if the mother suddenly stops breastfeeding?

A
  • Phenobarbital
  • Primidone
  • Benzodiazepines
  • Lamotrigine
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138
Q

Epilepsy

How should anti-epileptics be switched?

A

Cautiously

Only withdraw the first drug once new regimen has been established

Only withdraw ONE anti-epileptic at a time

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139
Q

Epilepsy

(1) What is an MHRA alert for anti-epileptic drugs? (2) How soon may these symptoms develop?

A

(1) Risk of suicidal thoughts and behaviours

(2) Symptoms may appear as early as one week after beginning treatment

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140
Q

Epilepsy

(1) What should be done if a patient has symptoms aligning with an MHRA warning for their anti-epileptic medication? (2) What are these symptoms?

A

(1) Seek medical advice
- Do NOT stop treatment, speak to HCP first

(2)
- Mood changes
- Distressing thoughts
- Suicidal ideation/ self-harm thoughts

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141
Q

Epilepsy

What is the advice on switching between different manufacturer’s products for anti-epileptic medication?

A

ONLY APPLIES FOR TREATMENT OF EPILEPSY:

(1) If maintaining on a SPECIFIC brand, brand should be specified

(2) If maintaining on a GENERIC brand, name and name of manufacturer (MA holder) should be specified

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142
Q

Epilepsy

What should be done if a patient experiences any adverse effects to anti-epileptics?

A

Report on Yellow Card

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143
Q

Epilepsy

(1) If a prescribed anti-epileptic is not available, what may it be necessary to do? (2) Who needs to agree to this?

A

(1) Dispense a product from a different manufacturer to maintain continuity of treatment

(2) Must be agreed by prescriber AND patient (or carer)

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144
Q

Epilepsy

Which anti-epileptics can cause Anti-epileptic Hypersensitivity Syndrome?

A
  • Carbemazepine
  • Phenytoin
  • Phenobarbital
  • Primidone
  • Lamotrigine
  • Lacosamide
  • Oxcarbazepine
  • Rufinamide
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145
Q

Epilepsy

(1) What are some common symptoms of Anti-epileptic Hypersensitivity Syndrome? (2) What are some more severe symptoms? (3) How soon may the more severe symptoms develop?

A

(1)
- Fever
- Rash
- Lymphadenopathy

(2) Liver dysfunction, haematological abnormalities, renal impairment, pulmonary issues, vasculitis, multi-organ failure

(3) Usually start 1-8 weeks after exposure

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146
Q

Epilepsy

What should be done if a patient has suspected Anti-epileptic Hypersensitivity Syndrome?

A

Withdraw drug immediately

Do not re-expose

Seek specialist advice

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147
Q

Epilepsy

What is the therapeutic range of carbemazepine?

A

4-12mg/L

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148
Q

Epilepsy

What are some signs of carbamazepine toxicity?

A
  • Hyponatraemia
  • Ataxia (loss of control of body movements)
  • Nystagmus (involuntary, repetitive movement of eyes)
  • Drowsiness
  • Blurred vision
  • Arrhythmias
  • GI disturbances
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149
Q

Epilepsy

Which drug is primidone converted into?

A

Phenobarbital

150
Q

Epilepsy

What is the therapeutic range of phenytoin?

151
Q

Epilepsy

What are signs of phenytoin toxicity?

A
  • Confusion
  • Hyperglycaemia
  • Ataxia (loss of control of body movements)
  • Nystagmus (involuntary, repetitive movement of eyes)
  • Double vision
  • Slurred speech
152
Q

Epilepsy

What is a common side-effect of phenytoin?

A

Can cause gingival hyperplasia

153
Q

Epilepsy

What is the pregnancy prevention programme (PPP) for?

A

Teratogenic medication

154
Q

Epilepsy

If a teratogenic medication must be used during pregnancy, how should this be managed?

A

Lowest effective dose

Divided doses OR m/r tablets (to avoid peak plasma concentrations)

155
Q

Epilepsy

What doses of sodium valproate are associated with teratogenicity?

156
Q

Epilepsy

What is the MHRA advice for sodium valproate in pregnancy?

A

Contra-indicated for migraine prophylaxis AND BPD

Must only be considered for epilepsy if there are no suitable alternatives

157
Q

Epilepsy

What are the monitoring requirements for sodium valproate?

A
  • Liver function: Before AND during first 6 months
  • FBC: To assess potential for bleeding, before starting AND before surgery
158
Q

Epilepsy

Why is routine monitoring of plasma valproate concentrations not useful?

A

Plasma valproate concentrations are not a useful index of efficacy

159
Q

Epilepsy

What are the cautions for sodium valproate use?

A
  • Liver toxicity
  • Pancreatitis (discontinue treatment)
  • Vitamin D (supplementation required)
  • SLE
160
Q

Epilepsy

When does liver toxicity, due to sodium valproate, most frequently occur?

A

In first 6 months (especially in children under 3)

161
Q

Epilepsy

If on sodium valproate treatment and raised liver tests are observed, what should be done?

A

Reassess clinically AND monitor liver function until returned to normal

Including prothrombin time

162
Q

Epilepsy

If a patient is on sodium valproate and their prothrombin time is abnormal, what should be done?

A

Discontinue treatment

163
Q

Epilepsy

When should immediate withdrawal of sodium valproate be considered?

A
  • Persistent vomiting AND abdominal pain
  • Jaundice
  • Oedema
  • Anorexia
  • Malaise
  • Drowsiness
  • Loss of seizure control
  • Pancreatitis
164
Q

Epilepsy

If sodium valproate treatment is stopped, over what period of time should this be done?

A

Gradually over 4 weeks

165
Q

Epilepsy

What are the cautionary labels for sodium valproate?

A

Label 8: Do not stop taking unless your doctor tells you to stop

Label 10: Read the additional information given with this medicine

Label 21: Take with or just after food, or a meal

166
Q

Epilepsy

What is the prodrug of phenytoin?

A

Fosphenytoin

167
Q

Epilepsy

How do the formulations of fosphenytoin compare to that of phenytoin?

A

Fosphenytoin: IM or IV

Phenytoin: IV only

168
Q

Epilepsy

What is a benefit of fosphenytoin over phenytoin?

A

(1) Fewer injection site reactions

(2) Can be given more rapidly than phenytoin

169
Q

Epilepsy

Why is carbemazepine not recommended in tonic, atonic, myoclonic, and absence seizures?

A

May exacerbate seizures

170
Q

Epilepsy

In what types of seizure must carbemazepine only be recommended in?

A

(1) Tonic Clonic

(2) Focal

171
Q

Epilepsy

Which anti-epileptics should be avoided in tonic, atonic, absence, and myoclonic seizures?

A
  • Carbemazepine
  • Oxcarbazepine
  • Gabapentin
  • Pregabalin
172
Q

Epilepsy

(1) In which type of seizure is lamotrigine not recommended? (2) Why?

A

(1) Myoclonic

(2) Can exacerbate and cause serious rashes

173
Q

Epilepsy

Is lamotrigine affected by enzyme inhibitors or inducers?

174
Q

Epilepsy

For which types of seizure is phenytoin not recommended?

A

(1) Absence

(2) Myoclonic

175
Q

Epilepsy

Which anti-epileptics should be prescribed as brand-specific?

A

Category 1
- Carbemazepine
- Phenobarbital
- Phenytoin
- Primidone

176
Q

Epilepsy

What are the category 1 anti-epileptics?

A
  • Carbemazepine
  • Phenobarbital
  • Phenytoin
  • Primidone
177
Q

Epilepsy

What are the category 2 anti-epileptics?

A
  • Clobazam
  • Clonazepam
  • Eslicarbazepine
  • Oxcarbazepine
  • Lamotrigine
  • Perampanel
  • Rufinamide
  • Topiramate
  • Sodium valproate
178
Q

Epilepsy

What are the category 3 anti-epileptics?

A
  • Brivaracetam
  • Ethosuxamide
  • Gabapentin
  • Pregabalin
  • Lacosamide
  • Levetiracetam
  • VIgabatrin
  • Tiagabine
179
Q

Epilepsy

Do category 2 anti-epileptics needs to be prescribed as brand-specific?

A

Base on clinical judgement AND consultation with patient

180
Q

Epilepsy

Do category 3 anti-epileptics needs to be prescribed as brand-specific?

A

Usually not necessary as equivalence can be presumed

181
Q

Epilepsy

For which anti-epileptic category can equivalence be presumed?

A

Category 3

182
Q

Epilepsy

Which anti-epileptic(s) are enzyme inducers?

A
  • Carbemazepine
  • Phenytoin
  • Phenobarbital
183
Q

Epilepsy

Which anti-epileptic(s) are enzyme inhibitors?

A

Sodium valproate

184
Q

Epilepsy

Which drugs can lower seizure threshold?

A
  • Quinolones
  • Tramadol
  • Theophylline
185
Q

Epilepsy

Which drug groups does carbemazepine interact with?

A

Drugs causing hyponatraemia:
- SSRIs
- Diuretics

186
Q

Epilepsy

Which drug groups does phenytoin interact with?

A

Anti-folates:
- Methotrexate
- Trimethoprim

187
Q

Epilepsy

What are some side-effects of carbemazepine, phenytoin, and sodium valproate?

A
  • Depression & suicide
  • Hepatotoxicity
  • Hypersensitivity
  • Blood dyscrasias
  • Vitamin D deficiency
188
Q

Epilepsy

What are some side-effects specific to carbemazepine?

A
  • Hyponatraemia
  • Oedema
189
Q

Epilepsy

What are some side-effects specific to phenytoin?

A
  • Coarsening appearance
  • Facial hair
190
Q

Epilepsy

What are some side-effects specific to sodium valproate?

A
  • Pancreatitis
  • Teratogenic effects
191
Q

Epilepsy

Which anti-epileptics can cause hypersensitivity?

A
  • Carbemazepine
  • Phenytoin
  • Phenobarbital
  • Primidone
  • Lamotrigine
192
Q

Epilepsy

Which anti-epileptics can cause skin rash (Stevens-Johnson syndrome)?

A
  • Lamotrigine most likely
  • Phenytoin (discontinue use)
  • Carbemazepine
  • Phenobarbital
193
Q

Epilepsy

Which anti-epileptics can cause blood dyscrasias?

A

C. VET. PLZ:

C: Carbemazepine

V: Valproate
E: Ethosuximide
T: Topiramate

P: Phenytoin
L: Lamotrigine
Z: Zonisamide

194
Q

Epilepsy

Which anti-epileptics can cause eye disorders?

A
  • Vigabatrin (reduced visual field)
  • Topiramate (secondary glaucoma)
195
Q

Epilepsy

Which anti-epileptics can cause encephalopathy?

A

Vigabatrin

196
Q

Epilepsy

Which anti-epileptics can cause respiratory depression?

A
  • Gabapentin
  • Pregabalin
197
Q

Bipolar Disorder

What is bipolar disorder?

A

Extreme fluctuation between manic phases and depressive phases

198
Q

Bipolar Disorder

What is the treatment for acute bipolar disorder?

A
  • Benzodiazepines
  • Antipsychotics (normally quetiapine/ olanzapine/ risperidone)
  • Lithium/ sodium valproate can be added in
199
Q

Bipolar Disorder

What is the prophylactic treatment for bipolar disorder?

A
  • Carbemazepine
  • Sodium valproate
  • Lithium
200
Q

Bipolar Disorder

What is are the symptoms of lithium toxicity?

A
  • Renal impairment (e.g. incontinence)
  • Extrapyramidal side-effects (e.g. tremors)
  • Visual disturbances (blurred vision)
  • Nervous system disorder (confusion & restlessness)
  • GI disorder (diarrhoea/ vomiting)
201
Q

Parkinson’s disease

Which hormone causes Parkinson’s disease?

A

Low dopamine

202
Q

Parkinson’s disease

What is the aim of Parkinson’s disease treatment?

A

To increase dopamine

203
Q

Parkinson’s disease

What is the treatment of Parkinson’s disease for patients whose motor symptoms decrease their quality of life?

A
  • Levodopa AND Carbidopa/ Benserazide
    ø Co-carelopa
    ø Co-beneldopa
204
Q

Parkinson’s disease

What is the treatment of Parkinson’s disease for patients whose motor symptoms do not decrease their quality of life?

A
  • Levodopa AND Carbidopa/ Benserazide
  • Non-ergot derived dopamine receptor agonist
  • Monoamine-oxidase-B inhibitors (MAO-B inhibitors)
205
Q

Parkinson’s disease

Which adjuvant to levodopa should be added on for patients who develop dyskinesia or motor fluctuations?

A
  • Non-ergot derived dopamine receptor agonist
  • MAO-B inhibitors
  • COMT inhibitors
206
Q

Parkinson’s disease

What are the side-effects of levodopa?

A
  • Impulse disorders
  • Sudden onset of sleep
  • Red urine
207
Q

Parkinson’s disease

How is sudden onset of sleep, in levodopa treatment, treated?

208
Q

Parkinson’s disease

What are some examples of non-ergot derived dopamine agonists?

A
  • Rotigotine
  • Pramipexole
  • Ropinirole
209
Q

Parkinson’s disease

What are some side-effects of non-ergot derived dopamine agonists?

A
  • Impulse disorders
  • Sudden onset of sleep
  • Hypotension
210
Q

Parkinson’s disease

How does the side-effect of impulse disorders from non-ergot derived dopamine agonists compare with that of levodopa?

A

Impulse disorders are worse in non-ergot derived dopamine agonists

211
Q

Parkinson’s disease

How should hypotension from non-ergot derived dopamine agonists be treated?

212
Q

Parkinson’s disease

What can happen if a MAO-B inhibitor is given with phenylephrine?

A

Can cause hypertensive crisis

213
Q

Parkinson’s disease

Which foods interact with MAO-B inhibitors?

A

Tyramine rich foods
- Marmite
- Yeast
- Tofu
- Salami
- Mature cheese

214
Q

Parkinson’s disease

Name some COMT inhibitors.

A
  • Entacapone
  • Tolcapone
214
Q

Parkinson’s disease

Name some COMT inhibitors.

A
  • Entacapone
  • Tolcapone
215
Q

Parkinson’s disease

What is a common discolouration caused by entacapone?

A

Red-brown urine

216
Q

Parkinson’s disease

What is the first line treatment for nocturnal akinesia?

A

Levodopa

OR

Oral dopamine receptor agonists

217
Q

Parkinson’s disease

What is the second line treatment for nocturnal akinesia?

A

Rotigotine patch

218
Q

Parkinson’s disease

Why is carbidopa/ benserazide given?

A

Prevent peripheral breakdown of levodopa before it crosses into brain

219
Q

Parkinson’s disease

What are some examples of impulse disorders?

A
  • Pathological gambling
  • Binge eating
  • Hypersexuality
220
Q

Parkinson’s disease

What are some examples of MAO-B inhibitors?

A
  • Rasagiline
  • Selegiline
221
Q

Parkinson’s disease

What are some side-effects of COMT inhibitors?

A
  • Entacapone: Red-brown urine
  • Tolcapone: Hepatotoxicity
  • Increases sympathetic side-effects: increase in CVD side-effects
222
Q

Parkinson’s disease

What are some side-effects of ergot derived dopamine receptor agonists?

A
  • Pulmonary reactions: SOB, chest pain, cough
  • Pericardial reactions: Chest pain
223
Q

Parkinson’s disease

What are some examples of ergot derived dopamine receptor agonists?

A
  • Bromocriptine
  • Cabergoline
224
Q

Psychosis & Schizophrenia

What are the types of symptoms in schizophrenia?

A
  • Positive symptoms
  • Negative symptoms
225
Q

Psychosis & Schizophrenia

What are some positive symptoms of schizophrenia?

A
  • Delusions
  • Disorganisation
  • Hallucinations
226
Q

Psychosis & Schizophrenia

What are some negative symptoms of schizophrenia?

A
  • Social withdrawal
  • Neglect
  • Poor hygiene
227
Q

Psychosis & Schizophrenia

Can an antipsychotic be used in a patient with Parkinson’s disease?

A

No

Has the opposite effect

228
Q

Psychosis & Schizophrenia

What are the types of antipsychotic drugs?

A

(1) 1st gen
- Phenothiazines (Group 1/2/3)
- Thioxanthenes
- Butyrophenones
(2) 2nd gen

229
Q

Psychosis & Schizophrenia

How many groups of phenothiazines are there?

230
Q

Psychosis & Schizophrenia

(1) What are the groups of phenothiazines? (2) Describe their sedative effect. (3) Describe their extrapyramidal side-effects (EPSEs) significance.

A

Group 1: Most sedation. Moderate EPSEs.

Group 2: Moderate sedation. Least EPSEs.

Group 3: Moderate sedation. High EPSEs.

231
Q

Psychosis & Schizophrenia

(1) What are some examples of thioxanthenes? (2) Describe the sedation and extra-pyramidal side-effects (EPSEs).

A

(1)
- Flupentixol
- Zuclopenthixol

(2) Moderate sedation & EPSEs

232
Q

Psychosis & Schizophrenia

What are some examples of butyrophenones?

A

(1) Benperidol/ haloperidol

(2) Moderate sedations and high EPSEs

233
Q

Psychosis & Schizophrenia

(1) What are some examples of butyrophenones? (2) Describe the sedation and extra-pyramidal side-effects (EPSEs).

A

(1) Benperidol/ haloperidol

(2) Moderate sedations and high EPSEs

234
Q

Psychosis & Schizophrenia

What are some examples of group 1 phenothiazines?

A
  • Chlorpromazine
  • Levomepromazine
  • Promazine
235
Q

Psychosis & Schizophrenia

What are some examples of group 2 phenothiazines?

A

Pericyazine

236
Q

Psychosis & Schizophrenia

What are some examples of group 3 phenothiazines?

A
  • Fluphenazine
  • Prochlorperazine
  • Trifluoperazine
237
Q

Psychosis & Schizophrenia

What are some examples of second generation anti-psychotics?

A
  • Amisulpride
  • Aripiprazole
  • Clozapine
  • Olanzapine
  • Quetiapine
  • Risperidone
238
Q

Psychosis & Schizophrenia

Which second generation anti-psychotic has the least side-effects?

A

Aripiprazole

239
Q

Psychosis & Schizophrenia

What are some anti-psychotic side-effects?

A
  • EPSEs
  • Hyperprolactinaemia
  • Sexual dysfunction
  • Cardiovascular side-effects
  • Hypotension
  • Hyperglycaemia
  • Weight gain
  • Neuroleptic malignant syndrome
240
Q

Psychosis & Schizophrenia

In which group of antipsychotics are EPSEs most common?

A

Group 3 phenothiazines and butyrophenones

241
Q

Psychosis & Schizophrenia

In which group of antipsychotics are EPSEs least common?

A

Second gen:
- Clozapine
- Olanzapine
- Quetiapine
- Aripiprazole

242
Q

Psychosis & Schizophrenia

What does hyperprolactinaemia lead to?

A
  • Sexual dysfunction
  • Reduced bone density
  • Menstrual disturbances
  • Breast enlargement
  • Galactorrhoea (milky nipple discharge, unrelated to breastfeeding)
  • Increased risk of breast cancer
243
Q

Psychosis & Schizophrenia

In which antipsychotic is hyperprolactinaemia least common?

A

Aripiprazole

244
Q

Psychosis & Schizophrenia

In which antipsychotics is hyperprolactinaemia most common?

A
  • First gen
  • Risperidone
  • Amisulpride
  • Sulpride
245
Q

Psychosis & Schizophrenia

In which antipsychotics is sexual dysfunction common?

A

All antipsychotics

246
Q

Psychosis & Schizophrenia

Which antipsychotics have the highest prevalence for sexual dysfunction?

A
  • Risperidone
  • Haloperidol
  • Olanzapine
247
Q

Psychosis & Schizophrenia

Which antipsychotics have the lowest prevalence for sexual dysfunction?

A
  • Aripiprazole
  • Quetiapine
248
Q

Psychosis & Schizophrenia

(1) Which cardiovascular side-effect is most common in antipsychotic treatment? (2) Which antipsychotic drugs cause this most?

A

(1) QT prolongation

(2)
- Pimozide
- Haloperidol

249
Q

Psychosis & Schizophrenia

Which antipsychotics are most likely to cause hypotension?

A
  • Clozapine
  • Quetiapine
250
Q

Psychosis & Schizophrenia

Which antipsychotics are most likely to cause hyperglycaemia?

A
  • Clozapine
  • Olanzapine
  • Risperidone
  • Quetiapine
251
Q

Psychosis & Schizophrenia

Which antipsychotics are most likely to cause weight gain?

A
  • Olanzapine
  • Clozapine
252
Q

Psychosis & Schizophrenia

(1) What should be done if a patient taking antipsychotics develops Neuroleptic Malignant Syndrome? (2) How should this be treated? (3) How long should this take to resolve?

A

(1) Stop treatment

(2) Treat with bromocriptin

(3) Should resolve in 5-7 days

253
Q

Psychosis & Schizophrenia

What are the monitoring requirements for antipsychotics?

A
  • Weight
  • Fasting blood glucose + HbA1c + blood lipid concentrations
  • ECG
  • Blood pressure
  • FBCs + U&Es + LFTs
254
Q

Psychosis & Schizophrenia

How frequently should weight be monitored in antipsychotic treatment?

A
  • Upon initiation
  • Weekly for first 6 weeks
  • At 12 weeks
  • At 1 year
  • Then yearly
255
Q

Psychosis & Schizophrenia

What contraindications are there for clozapine?

A
  • Seizures
  • Uncontrolled diabetes
256
Q

Psychosis & Schizophrenia

When is clozapine used?

A

Resistant schizophrenia

Only used when 2+ antipsychotics (inc. one 2nd gen) has been used for 6-8 weeks

257
Q

Psychosis & Schizophrenia

(1) What are the monitoring requirements for clozapine? (2) How frequently should this be done?

A

(1) Leucocytes + differential blood counts

(2) Weekly for 18 weeks, THEN fortnightly til one year, THEN monthly

258
Q

Psychosis & Schizophrenia

What are some side-effects of clozapine?

A
  • Myocarditis & cardiomyopathy
  • Agranulocytes + neutropenia
  • GI disturbances
259
Q

Anxiety

Which type of medication is used for the acute treatment of anxiety?

A

Benzodiazepines

260
Q

Anxiety

What is the chronic treatment of anxiety?

A
  • SSRI: Sertraline, citalopram, escitalopram, fluoxetine
  • Propranolol (alleviates physical symptoms only)
261
Q

Anxiety

How is an overdose of benzodiazepines?

A

Flumazenil

262
Q

Anxiety

What can overdose of benzodiazepines lead to?

A

Can induce hepatic coma

263
Q

Anxiety

What are some long-acting benzodiazepines?

A
  • Diazepam
  • Aprazolam
  • Chlordiazepoxide
  • Clobazam
264
Q

Anxiety

What are some short-acting benzodiazepines?

A
  • Lorazepam
  • Oxazepam
265
Q

Anxiety

When are short-acting benzodiazepines preferred?

A
  • Hepatic impairment
  • Elderly
266
Q

Anxiety

Which type of benzodiazepines (long or short) have a greater risk of withdrawal symptoms?

A

Short-acting

Therefore only use for 2-4 weeks

267
Q

Anxiety

Give some examples of waht can be used concomitantly with benzodiazepines to increase risk of sedation?

A
  • Alcohol
  • CNS depressants
  • CYP enzyme inhibitors
268
Q

Anxiety

Which benzodiazepines ahve a legal driving limit?

A
  • Clonazepam
  • Oxazepam
  • Lorazepam
  • Diazepam
  • Flunitrazepam
  • Temazepam

(COLD FT)

269
Q

Anxiety

What are some symptoms of benzodiazepine withdrawal?

A
  • Anxiety
  • Sweating
  • Weight loss
  • Tremor
  • Loss of appetite
270
Q

Anxiety

How can benzodiazepine withdrawal be managed?

A

(1) Convert to once nightly dose of diazepam

(2) Reduce by 1-2mg every 2-4 weeks (1/10th on larger doses)
ø Only withdraw further if patient has overcome any withdrawal symptoms

(3) Reduce further (by 0.5mg at end

271
Q

Depression

What is depression?

A

A reduction of serotonin, dopamine, or noradrenaline at the synaptic cleft

272
Q

Depression

What is the first line treatment for mild depression?

273
Q

Depression

When are antidepressants indicated in treatment of depression?

A

Moderate-severe

274
Q

Depression

What may a patient on treatment of depression experience in the first 1-2 weeks of pharmacological treatment?

A

Worsening of symptoms

275
Q

Depression

How long should antidepressants be taken for before they are deemed to be ineffective?

A

4 weeks

(6 weeks in elederly)

276
Q

Depression

How long should antidepressants be taken, after remission?

A

For 6 months - 2 years in recurrent

(1 year in elderly)

277
Q

Depression

What is the first line treatment of depression?

278
Q

Depression

What are the second line treatment options for depression?

A
  • Increase dose
  • Change SSRI
  • MIrtazepine
  • MAO-I
  • TCA/ venlafaxine (if severe)
279
Q

Depression

What is the third line treatment for depression?

A

Addition of another class, such as lithium/ other antipsychotics

280
Q

Depression

What is the treatment for severe refractory depression?

A

Electroconvulsive therapy

281
Q

Depression

What are the types of effects of serotonin syndrome?

A

(1) Cognitive effects
(2) Autonomic effects
(3) Neuromuscular excitation

282
Q

Depression

What are some cognitive effects of serotonin syndrome?

A
  • Headache
  • Agitation
  • Hypomania
  • Coma
  • Confusion
283
Q

Depression

What are some autonomic effects of serotonin syndrome?

A
  • Sweating
  • Hyperthermia
  • Nausea
  • Diarrhoea
284
Q

Depression

What are the symptoms of neuromuscular excitation in serotonin syndrome?

A
  • Myoclonus
  • Tremor
  • Teeth grinding
285
Q

Depression

Which drugs can cause serotonin syndrome?

A
  • SSRIs/ TCA/ MAOi
  • Triptans
  • Tramadol
  • Lithium
  • Linezolid
  • Bupropion
286
Q

Depression

Name some common SSRIs.

A
  • Fluoxetine
  • Citalopram
  • Escitalopram
  • Sertraline
287
Q

Depression

Which SSRI is considered safest in patients with a history of cardiac events?

A

Sertraline

288
Q

Depression

What is the SSRI of choice in patients under 17 yeras old?

A

Fluoxetine

289
Q

Depression

What are some side effects of SSRIs?

A
  • GI disturbances
  • Weight gain (appetite)
  • Sexual dysfunction
  • Risk of bleed
  • Insomnia
  • QT prolongation (citalopram/ escitalopram)
290
Q

Depression

Which SSRIs can cause QT prolongation?

A
  • Citalopram
  • Escitalopram
291
Q

Depression

What are some common interactions for SSRIs?

A

(1) CYP enzyme inhibitors
- avoid grapefruit juice (increases plasma concentration)

(2) CYP enzyme inducers
- reduces effectiveness

(3) Drugs that cause QT prolongation
- amiodarone/ stall/ quinolones

(4) Drugs that cause increased risk of bleeding

(5) Hyponatraemia
- carbemazepine/ diuretics

(6) Serotonin syndrome

292
Q

Depression

(1) Which antidepressant is better for agitated and anxious patients for treatment of depression? (2) Why?

A

(1) TCAs
(2) Sedating

293
Q

Depression

Which TCA antidepressants are sedating?

A
  • Amitriptyline
  • Clomipramine
  • Dosulepin
  • Trazodone
294
Q

Depression

Which TCA antidepressants are non-sedating?

A
  • Imipramine
  • Lofepramine
  • Nortriptyline
295
Q

Depression

What are some common side-effects of TCA antidepressants?

A
  • Cardiac events
  • Anti-muscarinic
  • Seizures
  • Hypotension
  • Hallucinations
296
Q

Depression

What are some interactions of TCAs?

A
  • CYP enzyme inhibitors (avoid grapefruit juice)
  • CYP enzyme inducers (reduces effectiveness)
  • Drugs that cause QT prolongation
  • Anti-muscarinic drugs
  • Anti-hypertensive drugs
  • Serotonin syndrome
297
Q

Depression

What are some examples of MAOis?

A
  • Tranylcypromine
  • Phenelzine
  • Isocarboxazid
  • Moclobemide
298
Q

Depression

Which MAOis can cause hepatotoxicity?

A
  • Phenelzine
  • Isocarboxazid
299
Q

Depression

Can tranylcypromine and clomipramine be given together?

300
Q

Depression

Which antidepressants have a washout period?

301
Q

Attention Deficit Hyperactivity Disorder

(1) Which type of formulation is preferred for treatment of ADHD? (2) Why?

A

(1) M/R

(2) Better pharmacokinetic profile, convenience, and improved adherence

302
Q

Attention Deficit Hyperactivity Disorder

Do M/R formulations for treatment of ADHD need to be brand specific?

303
Q

Attention Deficit Hyperactivity Disorder

What is the first line treatment for ADHD?

A

Methylphenidate (5yrs<)

304
Q

Attention Deficit Hyperactivity Disorder

What is the alternative treatment option for ADHD, if first line treatment is unsuccessful after 6 weeks?

A

Lisdexamfetamine

305
Q

Attention Deficit Hyperactivity Disorder

For treatment of ADHD, if lisdexamfetamine was helping but longer duration could not be tolerated, what can be used instead?

A

Dexamfetamine

306
Q

Attention Deficit Hyperactivity Disorder

What is the treatment of ADHD in patients who are intolerant of both methylphenidate and lisdexamfetamine?

A

Atomoxetine/ guanfacine

307
Q

Attention Deficit Hyperactivity Disorder

What is the second line treatment for ADHD in adults?

A

Atomoxetine

308
Q

Attention Deficit Hyperactivity Disorder

What are some side-effects/ cautions for atomoxetine?

A
  • QT prolongation
  • Hepatotoxicity
  • Suicidal ideation
  • Sexual dysfunction
309
Q

Attention Deficit Hyperactivity Disorder

What schedule are methylphenidate and lisdexamfetamine?

A

Schedule 2

310
Q

Attention Deficit Hyperactivity Disorder

What are the phases of overdose of amphetamines?

A

(1) Wakefulness, excessive activity, paranoia, hallucination, hypertension

(2) Exhaustion, convulsions, hyperthermia, coma

311
Q

Attention Deficit Hyperactivity Disorder

How does methylphenidate work?

A

CNS Stimulant

312
Q

Attention Deficit Hyperactivity Disorder

What schedule is methylphenidate?

A

Schedule 2

313
Q

Attention Deficit Hyperactivity Disorder

(1) What monitoring requirements are there for methylphenidate? (2) How frequently?

A

(1)
- Pulse
- BP
- Psychiatric symptoms
- Weight loss
- Height

(2) At initiation and then 6 monthly

314
Q

Attention Deficit Hyperactivity Disorder

What are some important side effects of methylphenidate?

A
  • High BP
  • Tachycardia
  • Arrhythmias
  • Behavioural changes
  • Drowsiness
  • Sleep disorders
  • Weight loss
  • Growth retardation
315
Q

Substance Dependence

How should mild alcohol withdrawal be managed?

A

Usually do not need assistance

316
Q

Substance Dependence

Where should moderate alcohol withdrawal be managed?here

A

Community

Unless at high risk of withdrawal seizures/ delirium tremens

317
Q

Substance Dependence

Where should severe alcohol withdrawal be managed?

A

Inpatient setting

318
Q

Substance Dependence

How should delirium in alcohol withdrawal be managed?

319
Q

Substance Dependence

How should Wernicke’s encephalopathy in alcohol withdrawal be managed?

A

Thiamine (vit B1)

320
Q

Substance Dependence

(1) How should alcohol dependence be managed? (2) How should withdrawal symptoms be managed?

A

(1) CBT/ acamprosate/ naltrexone

(2) Chlordiazepoxide/ diazepam (aslo can use carbemazepine/ clomethiazole)

321
Q

Substance Dependence

(1) What is the first line treatment for nicotine dependence? (2) When should this be avoided?

A

(1) Varenicline

(2) CVD/ psychiatric illness/ epilepsy

322
Q

Substance Dependence

(1) What is the second line treatment for nicotine dependence? (2) When should this be avoided?

A

(1) Bupropion

(2) Psychiatric illness, seizures, eating disorders, serotonin syndrome

323
Q

Substance Dependence

What is the third line treatment for nicotine dependence?

324
Q

Substance Dependence

Which script should opioid dependence treatment be prescribed on?

325
Q

Substance Dependence

In treatment of opioid dependence, how many missed doses are required for a patient to be referred back to a specialist?

A

3 or more missed doses

Re-titration needed

326
Q

Substance Dependence

Should opioid dependence treatment be continued in pregnancy?

327
Q

Substance Dependence

When should naloxone be presrcibed alongside opioid dependence treatment?

A

In high risk of overdose

328
Q

Substance Dependence

Give pros and cons of buprenorphine vs methadone in opioid dependence treatment.

A

BUPRENORPHINE:
- less sedating than methadone
- milder withdrawal symptoms
- lower risk of overdose

METHADONE:
- Can be carefully titrated according to patient’s need
- causes QT prolongation

329
Q

Migraines

What symptoms often accompany migraines?

A
  • Nausea + vomiting
  • Photophobia
  • Phonophobia
330
Q

Migraines

(1) What are some visual symptoms of migraines? (2) What are some sensory symptoms of migraines?

A

(1) Zigzag/ flickering lights, spots/ lines

(2) Pins/ needles, numbness

331
Q

Migraines

What is the lifestyle advice for a migraine?

A
  • maintain hydration, sleep + exercise
  • avoid chocolate + wine
  • relax after stress
  • create a headache diary (to help identify triggers)
332
Q

Migraines

What is the acute treatment of migraines?

A

Ibuprofen/ aspirin/ 5HT-1 agonist (preferably sumatriptan)

333
Q

Migraines

When should a -triptan be taken for a migraine?

A

At start of HEADACHE not at start of aura

334
Q

Migraines

How frequently can a -triptan be administered for migraines?

A

Can repeated after 2hrs (4hrs for naratriptan)

335
Q

Migraines

(1) When are triptans contraindicated? (2) Why?

A

(1) Heart disease

(2) Cause constriction of blood vessels

336
Q

Migraines

(1) For a migraine, when first line treatment options are not suitable, what can be used instead? (2) Why?

A

(1) Soluble paracetamol

(2) Faster acting, as it is already broken down (can also use any liquid preparation)

337
Q

Migraines

Which antiemetics are most suitable in treatment of migraines?

A

Metoclopramide/ prochlorperazine

338
Q

Migraines

What is the first line treatment for migraine prophylaxis?

A

Propranolol

339
Q

Migraines

What is the second line treatment for migraine prophylaxis?

A

Amitriptyline

340
Q

Migraines

What else can be used for migraine prophylaxis, if first and second line treatment options are unsuitable?

A

Sodium valproate/ pizotifen/ Botox

341
Q

Migraines

What are the different types of headache?

A
  • cluster
  • migraine
  • tension
342
Q

Migraines

What is the acute treatment of cluster headaches?

A

SC sumatriptan

343
Q

Migraines

What is the prophylactic treatment of cluster headaches?

A

Verapamil/ lithium/ prednisolone/ ergotamine

344
Q

Migraines

What is the treatment for trigeminal neuralgia?

A

Carbamazepine

(Or pregabalin/ gabapentin)

345
Q

Migraines

What is the treatment for a tension headache?

A

Paracetamol/ ibuprofen

346
Q

Nausea & Vomiting

Which antihistamines can be useful in prevention of nausea and vomiting?

A

Cyclising/ promethazine

347
Q

Nausea & Vomiting

Which antiemetics are most appropriate in postoperative nausea and vomiting?

A

5HT-3 receptor antagonist (e.g. ondansetron) or dexamethasone

348
Q

Nausea & Vomiting

Which antiemetics are most appropriate in preoperative nausea and vomiting?

A

Lorazepam (short-acting)

349
Q

Nausea & Vomiting

Which antiemetics are most appropriate in motion sickness nausea and vomiting?

A

Hyoscine hydrobromide

350
Q

Nausea & Vomiting

Which antiemetics are most appropriate in nausea and vomiting associated with a terminal illness?

A

Haloperidol/ levomepromazine

351
Q

Nausea & Vomiting

Which antiemetics are most appropriate in nausea and vomiting in a patient with Parkinson’s disease?

A

Domperidone

352
Q

Pain Management

What is the treatment for mild pain?

A

Non-opiates

Paracetamol/ NSAIDs/ aspirin

353
Q

Pain Management

What is the treatment for mild-moderate pain?

A

Weak opiates (codeine/ dihydrocodeine)

Moderate - tramadol

354
Q

Pain Management

What are some cautions with tramadol?

A
  • lowers seizure threshold
  • serotonin syndrome
  • increased risk of bleed
  • psychiatric disorders
355
Q

Pain Management

What is the treatment for moderate-severe pain?

A

Strong opiates

Morphine/ oxycodone/ fentanyl/ methadone/ buprenorphine

356
Q

Pain Management

What is the treatment for neuropathic pain?

A
  • TCAs (amitriptyline/ nortriptyline)
  • antiepileptics (gabapentin/ pregabalin)
  • opiates (tramadol/ morphine/ oxycodone)
  • topical localised (lidocaine/ capsaicin)
357
Q

Pain Management

What are the main side effects of opiates?

A
  • dry mouth
  • constipation
  • CNS depression
  • nausea and vomiting
  • hypotension
  • miosis (pupil constriction)
358
Q

Pain Management

What issues can prolonged opioid use contribute to?

A
  • hypogonadism
  • adrenal insufficiency
  • hyperalgaesia (pain sensitivity)
359
Q

Pain Management

What opioid dose can be used for breakthrough pain?

A

1/6th to 1/10th of total daily dose

Every 2-4 hours

360
Q

Pain Management

What are the main contraindications for use of opioids?

A
  • respiratory depression
  • head injury
  • paralytic ileus
361
Q

Pain Management

What is the maximum dose that methadone should be decreased to when switching to buprenorphine?

362
Q

Pain Management

Which is more potent, oxycodone or morphine?

A

Oxycodone

More appropriate in patients who can’t consume large quantities due to nausea

363
Q

Pain Management

When should a fentanyl patch be removed if there are signs of toxicity?

A

Immmediately

364
Q

Pain Management

What effect can temperature have on fentanyl patches?

A

Concentrations may increase if skin temperature increases

365
Q

Pain Management

(1) In what age groups can codeine be used? (2) What about codeine linctus?

A

(1) >12yrs old - >18yrs old if tonsils removed due to sleep apnoea

(2) >18yrs old

366
Q

Pain Management

Which ethnicity is known to be at increased risk of being ultra-rapid metabolisers of codeine?

A

Afro-Caribbean

367
Q

Pain Management

(1) In which ethnicity should codeine be avoided/ used with caution? (2) Why?

A

(1) Afro-Caribbean

(2) Risk of toxicity if ultra-rapid metabolisers

368
Q

Pain Management

Can codeine be used in breastfeeding patients?

369
Q

Pain Management

Which pathway do opioids act on?

A

Mu pathway

Pre-Reg (Trainee) Pharmacy (31 decks)

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