masterclass 2: MSK and rheumatology Flashcards
1
Q
benign essential tremor patter
A
tremor is worse on movement and reduced at rest
2
Q
drugs that can induce parkinsons x4
A
SSRIs, beta-blockers, lithium, anti-psychotics
3
Q
Multiple system atrophy response to levodopa
A
poor
4
Q
how does Progressive supranuclear palsy differ from parkinsons
A
early instability and vidual probs (vertical gaze palsy)
5
Q
how is LBD dif from parkinsons
A
memory loss before motor symptoms
6
Q
what is dopamine use for
A
corordination of movement in the direct and indirect pathways in basal galnglia
7
Q
parkinsons pathology
A
loss of dopaminergic neurons in the substantia nigra
8
Q
parkinsons triad
A
Resting tremor
Bradykinesia
Skeletal muscle rigidity
9
Q
what drug increases dopamine levels
A
levodopa
10
Q
what drugs reduce the breakdown of dopamine
A
MAOB inhibitors and COMT inhibitors
11
Q
what drugs act directly on the dopamine receptors/dope agonist
A
Pramipexole/Ropinirole
12
Q
choice of drug in early Parkinsons
A
dopamine agonists or MAO-BIs
13
Q
which drug is better for the motor symptoms of parkinsons
A
levodopa
14
Q
who is more likely to get the motor symptoms of levodopa
A
younger people
15
Q
examples of MAOB inhibitors x2
A
selegiline, rasagiline
16
Q
which drug most effectively treats parkinsons
A
levodopa
17
Q
when to use amantadine
A
dyskinesia isnt controlled by other meds
18
Q
what is dyskinesia
A
impairment of voluntary movement.
19
Q
useful adjuvant to enhance levodopa
A
COMT inhibitors - stop it being broken down and prolong levodopa
20
Q
when is an anticholinergic used in parkinsons
A
For disabling tremor and excessive salivation
21
Q
what actually is levodopa
A
amino acid precurser of dopamine
22
Q
dopamine and the BBB
A
cant cross
23
Q
can levodopa cross BBB
A
yes
24
Q
what else can convert levodopa
A
peripheral dopa-decarboxylase
25
Carbidopa moa
Dopa decarboxylase (DDC) inhibitor
26
name another Dopa decarboxylase (DDC) inhibitor
benserazide
27
dopamine and
controls the flow of information in the frontal lobe
28
loss of dopamine and cognition
memory problems
29
excess of dopamine and cognition x2
psychosis and Schizophrenia
30
dopamine and boobs
Prolactin inhibitory hormone, acting on D2 receptors, preventing lactation
31
dopamine and sick
emesis function
32
dopamine and GI
Inhibits gastric stimulation
33
dopamine and the heart
Dopamine is converted to norepinephrine
34
dopamine antagonist example - GI motility
Domperidone
35
dopamine antagonist example - emesis
Example of an antagonist is Metoclopramide
36
dif between noradrenaline and adrenaline
noradrenalin is released continuously and adrenalin is released in times of stress
37
indication for Co-careldopa
parkinsons only
38
co-beneldopa indication
only parkinsons
39
levodopa contraindications
Breast feeding
Severe psychiatric illness
Caution in severe pulmonary or cardiovascular disease
Severe nausea/GI motility problems
40
what is the problem with dopamine drugs and cardiovascular
converted to noradrenaine and adrenaline = tachycardia and hypertension
41
what other endocrine abnormality does dopamine cause other than prolactin
reduce thyrotropin
42
what is thyrotropin
TSH
43
common side effects of levodopa
Nausea and vomiting
Abnormal dreams and sleep disturbances
Dizziness and syncope
44
abnormal sleep and carledopa x3
sudden onset of sleep
wierd dreams
insomnia
45
motor problem in patients taking carledopa and what body part they affect
Involuntary movements, or dyskinesia, usually affecting the face and limbs
46
when do the carledopa motor symptoms start
within 2 years
47
carledopa and clinical state
on-off effect, rapid worsening of symptoms for mins/hours
48
levodopa and BP
can cause postural hypotension
49
levodopa psychological side effects
dementia, depression and schizophrenia-like syndrome with delusions and hallucinations
50
levodopa interactions
Monoamine oxidase inhibitors
General anaesthetics
Anti-hypertensives
51
advice for patients taking levodopa
dont stop abruptly - MNS
52
interaction between levodopa and MAOi
hypotension
53
interaction between levodopa and GA
arrhythmia
54
risky activities with levodopa
driving and heavy machinery
55
4 solutions to the wearing off phenominom
Adjust the dose
Smaller, more frequent doses
Prolonged-release levodopa preparations
take levodopa 30 minutes before food
56
when to take Prolonged-release levodopa preparations
bedtime
57
3 ways to manage on off fluctuations of levodopa
Combine levodopa with a dopamine agonist
Fewer doses of levodopa
Liquid forms of levodopa
58
Pathophysiology of NMS
Depletion of dopamine in the hypothalamus/nigrostriatal pathway
59
signs of NMS
rigidity, fever, altered GCS
60
NMS management x3
mainly supportive, some evidence for use dantrole, bromocriptine or Lorazepam
61
whats dantrolene
muscle relaxer
62
what does diagnosis of epilepsy require
2 unprovoked seizures, more than 24 hours apart
63
whats a seizure
Sudden, transient and unpredictable occurrence of signs and symptoms due to abnormal electrical activity in the brain
64
cerebrovascular causes of seizure x3
infarction, haemorrhage or venous thrombosis
65
other causes of seizure - loads
head injury, intra-cranial surgery, CNS infections (meningitis/encephalitis), neurodegenerative diseases (dementia), autoimmune disease, neoplasm, genetic causes, drugs, metabolic disturbance
66
indications for starting AED
after one seizure if neurological deficit, EEG shows epileptic activity, risk of further seizure unacceptable, structural abnormality on brain imaging
67
dyscognitive seizure
impaired awareness
68
Generalised seizures
discharge affects the whole brain and associated with impaired consciousness
69
focal seizure AED
lamotrigine or carbamazapine
70
Generalised seizures AED
Na V
71
drug that Suppresses the initial seizure discharge and the spread of seizure activity
Na V
72
moa of Na V x4
potentiation of inhibitiory GABA effects
use-dependent blockade of sodium channels stabilising neuronal membranes
attenuation of excitatory glutamate
inhibition of T-type calcium channels.
73
contraindications to Na V x2
pmh/fmh of hepatic dysfunction
| metabolic disorders
74
NaV side effects x5
```
GI disturbances
Weight gain
Transient hair loss with regrowth of curly hair
Neurological features
Blood dyscrasias
```
75
AED drug that causes weight gain
NaV
76
AED that causes hair loss
NaV
77
examples of metabolic disorders that are contraindicated with NaV x3
porphyrias
mitochondrial disorders
urea cycle disorder.
78
what is prophyria important for
haemoglobin function
79
GI problems with NaV x
N+V, anorexia, abdominal pain, bowel disturbance to pancreatitis and hepatotoxicity
80
AED that can cause pancreatitis and hepatotoxicity
NaV
81
NaV and neurological problems x5
ataxia, tremor, confusion, encephalopathy, coma
82
Blood dyscrasias and NaV x2
anaemia and thrombocytopenia
83
which drugs run the risk of hepatotoxicity with NaV x5
Statins, alcohol, antibiotics, anti-fungals, chemotherapy agents
84
interaction drugs with NaV
Cytochrome P450 inhibitor
85
monitoring with NaV
monitor LFTs before and for first 6 months
86
what to do before surgery with NaV
FBC - bleeding risk
87
when to do NaV drug concentration levels
Suspect non-adherence or toxicity
| Clinical conditions such as status epilepticus or organ failure
88
which AED is safe during pregnanct
lamotrigine - same as background risk
89
lamotrigine moa
Use-dependent inhibition of sodium channels. Stabilises presynaptic neuronal membrane, suppressing release of excitatory amino acid glutamate which plays a key role in the generation of seizures
90
lamotrigine target
Selectively targets neurons that synthesise glutamate and aspartate.
91
cautions for lamotrigine
myoclonic seizures and Parkinson’s disease
| Renal failure and hepatic failure
92
why is lamotrigine contraindicated with parkinsons
exacerbates
93
why is lamotrigine contraindicated with mycoclonic seizures
exacerbates
94
lamotrigine side effects x5
```
Hypersensitivity syndrome
Rashes
GI disturbances
CNS effects
Bone marrow suppression
```
95
lamotrigine and hypersensitivity syndrome features x4
fever, rash, lymphadenopathy and hepatic dysfunction
96
lamotrigine and rashes
can be self-limiting
| Stevens-Johnson syndrome and toxic epidermal necrolysis
97
lamotrigine and CNS problems
drowsiness, headache, fatigue, dizziness, double vision, ataxia and tremor
98
AED that can suppress bone marrow
lamotrigine
99
which drugs might increase the CNA side effects when combined with lamotrigine x6
Alcohol, anti-psychotics, local anaesthetics, opioids, anti-histamines, benzodiazepines
100
lamotrigine and COCP
reduces contraceptive efficacy
101
lamotrigine and desogestrel
increased lamotrigine exposure
102
AED and pregnancy
offered 5 mg per day of folic acid before any possibility of pregnancy
103
SUDEP
sudden unexpected death in epilepsy
104
risk factors for SUDEP x4
tonic-clonic seizures, refractory epilepsy, AED polytherapy and associated neurological co-morbidity
105
how to minimise the risk of SUDEP
seizure control
106
define stroke
sudden onset focal neurological deficits
107
main imagine in acute setting of stroke
CT
108
CT of acute ischemic stroke
Hyperdense MCA sign
109
what is used for thrombolysis
alteplase
110
when to start alteplase
presentation withing 4.5 hours and haemorrhage is excluded
111
whats altaplase
copy of tissue plasminogen activator (t-PA)
112
what does tissue plasminogen activator do
coverts plasminogen to plasmin
113
whats plasmin
enzyme responsible for clot breakdown and fibrinolysis
114
alteplase contraindications - other than bleeding/past brain bleed/susceptible to bleeding x7
```
neurosurgery/head trauma/stroke in past 3 months
uncontrolled hypertension
known AV malformation/neoplasm/aneurysm
suspected endocarditis
abnormal blood glucose
```
115
relative contraindications for alteplase - about the stroke x3
Minor/rapidly improving symptoms
seizure at stroke onset
severe stroke
116
side effects of altaplase x5
```
Haemorrhage
Anaphylactic reactions
Hypotension
Nausea and vomiting
Cerebral oedema
```
117
other relative contraindications of alteplase
major surgery or serious trauma in previous 2 weeks
previous GI/urinary tract haemorrhage in previous 3 weeks
recent lumbar puncture or arterial puncture
post MI pericarditis
pregnancy
118
why do you get hypotension with alteplase
enzymatic release of the vasodilator bradykinin
119
what to do if someone gets hypotension with alteplase
stop = rapid recover and can continue
120
why do you get cerebral oedema with alteplase
reperfusion
121
do you use aspirin in acute ishcemic stroke
yes start within 24 hours, after if had thrombolysis
122
how long are people on aspirin for with ischemic stroke
2 weeks and then swap to antithrombotic
123
standard anti thrombotic for acute stroke
clopidogrel 75mg
124
clopidogrel Target
ADP Receptor
125
clopidogrel action
Irreversible Inhibitor
126
clopidogrel effect
Inhibits binding of adenosine diphosphate (ADP) to its platelet receptor
127
clopidogrel overall effect
inhibits platelet aggregation
128
clopidogrel contraindicatons x3
Active bleeding
Avoid in pregnancy
Caution in hepatic/renal impairment
129
clopidogrel and surgery
stop 7 days before
130
clopidogrel side effects x6
```
Bleeding
GI disturbances
Rashes
Headache
dizziness
paraesthesia
```
131
clopidogrel interactions x6
```
Anticoagulants and anti-platelets
NSAIDs
SSRIs
PPIs
Erythromycin
```
132
PPIs and erythromycin and fluoxetine interaction with clopidogrel
reduces antiplatelet effect
133
which antithrombotic can cause parasthesia
clopidogrel
134
3 CV things you might want to investigate for stroke pt
Ipsilateral carotid artery stenosis
Atrial fibrillation
Structural cardiac disease
135
carotid artery stenosis test
carotid doppler
136
who should receive surgery for carotid artery stenosis
50-99% or 70-99%
137
when should people get surgery for carotid artery stenosis
2 weeks post stroke
138
scores to calculate with stroke patients
chadsvasc and hasbled scores
139
whats chadsvasc for
AF stroke risk
140
hasbled score
risk of major bleeding for patients on anticoagulation
141
structural cardiac disease investigation
echo
142
stroke pt systolic BP should be below
130
143
atorvastatin moa
HMG-CoA reductase inhibitors
144
atorvastatin and LDL
more clearnace due to more receptors
145
atorvastatin cautions x6
```
Elderly patients
High alcohol intake
liver disease
Hypothyroidism
Patients at risk of muscle toxicity
Haemorrhagic stroke
```
146
atorvastatin interactions x3
Macrolide antibiotics
Penicillin antibiotics
Colchicine
147
atorvastatin and macrolids
increased statin exposure
148
atorvastatin and penicillins
increased risk hepatotoxicity
149
atorvastatin and colchicine
increased risk of rhabdomyolysis
150
stroke and driving rules
cant drive for one month
