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MP422 CNS > L1 - L7 > Flashcards

L1 - L7 Flashcards

1
Q

3 Features of Childhood CNS Disorder

A
  1. arising from impaired brain development / functional deficits. child’s development is slowed
  2. often occurs as co-morbidities and lead to substance misues
  3. requires treating the mind (CBT) and brain (medicines)
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2
Q

ASD

  • Neurodevelopment disorder
  • Rett’s caused by MECP2 gene
A
  • repetitive behaviour , communication deficit , poor social skills
  • 70% have co-morbid conditions (anxiety depression, ADHD)
  • if normal IQ with ASD they are likely to have increased visual and math ability
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3
Q

ASD Treatment

  • risperadone only licensed in 5 - 17 yrs
A
  • support of individual and family
  • no meds for Core Autism

unless : children with aggression give Risperidone (anti-psychotic)
- 2mg/day up to 45kg –> 3.5mg/day >45kg
- only for children

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4
Q

ADHD Overview (neurodevelopmental)

  • Pre Frontal cortex has defective inhibitory response.
A

Symptoms : inattention, hyperactivity, impulsivity

2/3 ADHD patients have co-morbidity
- tics , OCD , depression , substance misuse

Treatment
- methylphenidate
- used in children over 6yrs old

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5
Q

ADHD Diagnosing

  • diagnosed by clinical interview and standardised reports
A

Symptoms :
- inattention / hyperactivity / impulsivity

  • all 3 symptoms must be present in different settings (school, home)
  • must present before 12 years old
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6
Q

Tourette’s Syndrome

  • Tics - vocal and physical
  • often associated with ADHD or OCD
A

underlying problem in basal ganglia which controls motor skills and behaviours

Treatment
- 1st line CBT therapy
- HRT fixes bad habits
- ERP exposes you to triggers in safe environment
- can use risperidone

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7
Q

OCD

  • mild : <1hr / day
  • moderate : 1-3hrs / day
  • severe : >3hrs a day
A

Obsession: unwanted thoughts/urge that enters the mind repeatedly (anxiety)

Compulsion: repetitive behaviour to temporarily relieve unpleasant feelings brought by obsessive thought

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8
Q

Body Dysmorphic Disorder (BDD)

  • Fears and anxiety about physical appearance
A

Treatment Same as OCD
- treat with SSRI’s (inc. serotonin levels)

1st line : sertraline in children with OCD
1st line : fluoxetine for children with BDD
OR children with OCD + depression

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9
Q

Eating Disorders

  • anorexia nervosa , bulimia , binge eating
  • also use CBT, interpersonal & dietary counselling
A

Anorexia Nervosa

  • pathological need to keep weight low as possible
  • caution with drugs because heart is weakened by emaciation
  • SSRI’s commonly prescribed or (SGA’s)

Bulimia

  • periods of binge eating and being deliberately sick or using laxatives
  • Fluoxetine given at higher dose than depression
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10
Q

Neurodevelopmental Disorders

e.g. ASD & ADHD

A
  • impairments in cognition, behaviour or communication from abnormal brain development
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11
Q

Emotional/Behavioural Disorders

  • depression, anxiety, OCD, phobias, anorexia
A

internalising or externalising problems, usually as a consequence of stress

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12
Q

Psychotropic Drugs

A
  • Antidepressants - SSRI’s , SNRI’s
  • Antipsychotics - risperidone
  • AEDs - lamotrigine , sodium val
  • Psychostimulants - methylphenidate

Miscellaneous – [hypnotics, anxiolytics,
adrenergic agents]

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13
Q

Behavioural Therapies

  • CBT (ERP, HRT)
A

CBT - identifying and modifying unwanted thought patterns/behaviours rather than symptoms

better than drug use: - no side effects
- tackles root problem
- no withdrawal symptoms like with drugs
- prevents dependency from drug use

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14
Q

Anti Psychotics

  • 1st gen typical FGA’s
A
  • causes ED, EPS (tremors, parkinons effects)
  • arises from blocking D2 channels in nigro-strital pathway
  • blocks Dopamine receptors in different pathways.
  • to reduce nt for positive symptoms
  • haloperidol , chlorpromazine
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15
Q

SGA Antipsychotics

  • clozapine , risperidone ,
A
  • less extra-pyramidal side effects because it doesnt fully block dopamine receptor
  • most effective is clozapine (treatment-resistant schizo)
  • more cardiotoxic + causes weight gain (metabolic Syndrome)
  • effective for positive AND negative symptoms
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16
Q

Antipsychotic Monitoring Req’s

A

Weight - initial + every 3 months
U+E’s - baseline and annually
Blood Glucose - initial + every 3 months
Prolactin - if hyperprolactinaemia symptoms
ECG - if patient has cardia risk

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17
Q

ADHD Management Stages

  • preschool , mild ADHD , Moderate/severe
A

Pre School Overactivity
- behaviour management from parents, teachers

Mild ADHD
- general behaviour management & ADHD-specific training
- no meds at this stage because it can cause long term damage

Moderate/Severe
- when symptoms impact learning, relationships, self esteem
- medicine used here for symptoms

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18
Q

ADHD Treatment

  • 1st line CBT
  • can use methylphenidate, dexamphetamine , atomoxetine , gaun
A

Drug Treatment

1st line - psychostimulants
- methylphenidate , then dexamphetamine

2nd line - Atomoxetine or Guanfacine

3rd line Clonodine

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19
Q

Methylphenidate + Dexamphetamine

  • MoA
  • psychostimulant meds
A

Methylphenidate

  1. blocks dopamine and NA transporters which degrade NA & Dopamine
  2. increases neuronal transmission
  3. regulates focus and emotion

Dexamphetamine

  1. stimulates dopamine release from pre-synaptic vesicle
  2. and blocks the reuptake transporter
20
Q

Atomoxetine + Guanfacine

  • non-stimulants
A

Atomoxetine
1. NA transporter inhibitor , A2 agonist.
2. stops NA being degraded
3. metabolised by CYP2D6 (hepatic)

Guanfacine
- sustained release is licensed (long time till therapeutic effect)
- has calming effect

Clonidine
- inhibits NA release by stimulating alpha2 adrenergic system
- unlicensed. 2-3x / day dosing
- major S/E BP drop

21
Q

Tics Medication

AP’s - first and second gen

A

clonidine - but has s/e
- drowsiness , depression , major BP drop

Tics + Anxiety
- use SSRI’s

Co-morbid with ADHD
- atomoxetine non stimulant
- because stimulant drugs exacerbate tics

22
Q

OCD Medication

mainly psychological treatment
- CBT
- antidepressants if severe

A

SSRI’s 1st

  • sertraline 150mg daily
  • clomipramine (ssri) 300mg daily
  • used to treat delusions
23
Q

Depression

  • only treat children in severe cases
  • discontinuation reduce by 25% weekly
A

mostly SSRI

1st line : sertraline 50mg/day
2nd - fluoxetine or citalopram

NOT paroxetine because of very short half life leads to dependence
NOT venlafaxine because of s/e
NOT TCA’s

24
Q

Seizures Diagnosis

  • Transient Seizure :
  • due to abnormal or excessive activity
  • affects 1/100
A
  • Diagnosis :
  1. at least 2 unprovoked seizures >24hr apart
  2. one unprovoked seizure with 60% recurrence chance within 10yrs of original seizure
  3. diagnosis of epilepsy syndrome
25
Q

Generalised Seizures Classes

  • arising in both hemispheres engaging bilaterally
A

Atypical absence
– can’t respond , longer than 10 seconds

Typical Absent - altered awareness

Clonic – both arms jerking

Tonic – both arms go stiff

Atonic – going limp

26
Q

Generalised Seizures

  • status epilepticus
A
  1. results from failure of mechanisms for seizure termination
  2. failure of mechanisms responsible for abnormal seizure initiation
27
Q

Focal Seizures

  • one sided
  • can also develop into secondary generalised seizures (bilateral convulsive)
A

Aura , Motor , Automatic , Awareness/Responsiveness

Acquired : accidents/injury or genetic

infectious : bacterial or viral encephalitis

Metabolic : GLUT1 deficiency leading to more glutamate in brain, more excitation

Genetic :
- SCN1a - codes for Na+ channels increasing excitability causing epilepsy
- called Dravets Syndrome

28
Q

Seizure Sequence

  • stage 1 - 3
A

Initiation - abnormal voltage-gated channel action

Synchronisation - abnormal receptor-operated channel action

Propagation - recruitment of neurons via anatomical connection

29
Q

Treatment Strategies

  • AED’s Action
A
  1. inhibition of voltage gated Na+ channels , reducing sodium can reduce excitability
  2. promotes inhibitory neurotransmitters (GABA)
  3. inhibition of voltage-gated Ca2+ channels to stop muscle contraction
30
Q

AED Classes

A
  1. Na+ channel inhibition
  • phenytoin , carbamazepine , oxcarbazepine
  • lamotrigine ( 1 & 3 HVA Ca+ inhobition )
  • dont fully block Na+ channels , they just prolong inactive period (refractory)
  1. enhance GABA action
  • BZD’s - inc. frequency of GABAa channel opening
  • Phenobarbital - inc. probability of GABAa channel opening
  • Vigabatrin - inhibits GABA transaminase

–> they reduce nerve firing by Cl- influx into neuron to hyperpolarise

  1. Inhibit Ca2+ Voltage Channels
  • ethosuximide - inhibits T-type Ca2+ channels (used for absence seizures)
  • pregabalin - inhibits HVA Ca2+ and glutamate
  • Gabapentin - inhibits HVA Ca2+ and NA+ channels
31
Q

Seizures Treatment Guidelines

A

Generalised Seizures
- 1st line sodium valproate
- 2nd lamotrigine/topiramate

Focal Seizures
- 1st lamotrigine
- 2nd carbamazapine

Absence Seizures
- 1st ethosuximide
- 2nd sodium valproate/lamotrigine

Status Epilipticus
-1st midazolam (buccal) cuz BDZ’s have fast action
- 2nd lorazepam/diazepam

32
Q

Anti Epileptic Drug Transport

  • sodium valproate
  • lamotrigine
  • etho + midazolam
A

Sodium Valproate
- diffusion and carrier-mediated transport
- via monocarboxylate transporter

Lamotrigine
- carrier mediated transport
- via organic cation transporter (OCT1)

33
Q

Neurological vs Psychiatric

  • differences
A

Neurological - issues of the brain
- physical issue
- drug therapy is usually essential
- parkinsons , epilepsy , tumour , migraine

Psychiatric - issues of the mind
- disorders of mood, thought, behaviour
- psychological and drug treatment
- anxiety , depression , schizo

34
Q

Enteric Coated Tablets

  • polyvinyl actetate phthalate is coating
A
  • dissolve in duodenum at higher pH
  • sodium valproate
  • cannot crush or chew tablets as drug could be released too early
35
Q

Oro dispersible Tablets

  • Co-beneldopa & lamotrigine
A
  • tablet disintegrates in mouth in 1min in the saliva
  • no difficulty swallowing
  • more accurate dosing in kids
  • can be dissolved in water before administration
36
Q

Modified Release Tablets

  • erosion controlled matrix (sinemet)
  • diffusion control (ropinirole)
A
  • Erosion Controlled Matrix (co-careldopa sinemet)
  1. drug dispersed in a wax matrix
  2. matrix breaks down over time and drug is released slowly while matrix breaks down
  • Diffusion Control (ropinirole (ReQuip XL)(PD)
  1. drug dispersed in porous matrix formed of a water-insoluble polymer
  2. drug close to the surface dissolves
  3. rest of the drug diffuses slowly through the pores
37
Q

Modified Release Tablet

  • Erosion + Diffusion Controlled Matrix
A
  • sodium valproate (Epilim Chrono, Epival CR)
  • pramipexole ER (Mirapexin , PD)
  1. drug is dissolved and erodable matrix separates from drug
  2. over time the drug is released based on equilibrium changing once drug enters systemic uptake
38
Q

Transdermal Administration

  • requirements
A
  • have low molecular weight <400
  • aqueous solubility higher than 1mg/ml (to be removed by blood)
  • moderately lipophilic (LogP 1-5)
  • effective at low doses
  • Co-Beneldopa given as pump
  • Lorazepam given IM
39
Q

Dopamine Peripheral S/E

A

comes from dopamine release before BBB

  • stimulates vomiting centre in brain because its outside the BBB
  • can cause schizophrenia
  • increases excitability
40
Q

Extended Release Tablets

-carbamazepine (Tegretol XR) (epilepsy)

A
  1. overcoat disintegrated releasing 22% of drug instantly
  2. water permeates into osmotic layer, expanding this layer and pushing drug out over the span of a morning
  3. release rate inc. into the afternoon. more drug pushed out from push compartment expanding
41
Q

Headache Aetiology

A
  1. Pain stimuli activates nociceptors in skin, muscle, joints
  2. transmits signal from periphery nerves to brain - nociceptors in dura and pia.
  3. chemicals released from blood vessels near dura & pia activate nociceptors

= gives headaache

42
Q

Headache Types

  • Primary , Secondary
A

Primary - headache is main symptom
- stress/tension headache
- migraine
- cluster

Secondary - caused by something else
- symptom of something else

43
Q

Primary Headache Types

  • Tension , Migraine , Cluster
  • migraine is neurological
A

Tension
- slow onset , bilateral , dull pain
- pain in posterior

Migraine (no aura)
- unilateral , lasts 4-72hr , pulsating , moderate/severe , nausea vomiting

Migraine (with aura)
- headache with 1 of following :
- visual, sensory, speech, motor, retinal
- REFER

Cluster
- severe pain, one sided, behind the eye
- lasts weeks or months
- swelling & runny nose

44
Q

Primary Headache Treatment

  • paracetamol (inhibits prostaglandins)
  • Ibuprofen (COX inhibitor)
  • buclizine ( anti histamine and anti emetic)
A

paracetamol - inhibits prostaglandins production in pain pathway
- activates descending serotoninergic pathway

Ibuprofen - acts on COX1/2 receptors inhibiting prostaglandin synthesis

Buclizine - anti-histamine and anti-emetic. sedating

45
Q

General Headache Treatments

  • triptans - selective 5-HT antagonist
  • Pizotifen (serotonin , histamine & tryptamine)
  • Propranolol (blocks B-adrenoreceptor)
A

Triptans - stimulates 5-HT1b in smooth muscle to cause cranial vasoconstriction
- sumatriptan

Pizotifen - reduces blood flow & alters pain threshhold
- POM

Propanolol - reduces blood flow by blocking Beta receptors
- rizatriptan + propranolol bad reaction

MP422 CNS (4 decks)

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