Nervous system Flashcards
DISCUSS ACETYLCYSTEINE (paracetamol) CLINICAL PHARM
Drug: Acetylcysteine
MOA:
Paracetamol is a weak inhibitor of cyclo-oxygenase (COX), the enzyme involved in prostaglandin metabolism
- Acetylcysteine reverses paracetamol overdose
Indications:
- Paracetamol is a first-line analgesic for most forms of acute and chronic pain.
- Paracetamol is an antipyretic that can reduce fever and its associated symptoms
Adverse effects:
- overdose, paracetamol causes liver failure
Warnings/caution:
- ▴chronic excessive alcohol use
- ▴malnutrition
- ▴low body weight (<50 kg)
- ▴severe hepatic impairment
Contraindications:
- No contraindications
Interactions:
- CYP inducers, e.g. phenytoin and carbamazepine risk of liver toxicity after paracetamol overdose.
Monitoring:
- aim of reducing or relieving pain
- Efficacy of paracetamol in pain control can be established by enquiry about symptoms or by using a pain score
DISCUSS OPIOIDS CLINICAL PHARM
Drugs: morphine, oxycodone
MOA:
- The therapeutic action of opioids arises from activation of opioid µ receptors in the central nervous system (CNS), helps reduce pain transmission.
Indications:
- Rapid relief of acute severe pain
- Relief of chronic pain
- Relief of breathlessness in the context of end-of-life care
- Relief of breathlessness and anxiety in acute pulmonary oedema
Adverse effects:
- respiratory depression
- neurological depression
- causing nausea and vomiting
- Pupillary constriction
- constipation
- itching, urticaria, vasodilatation and sweating
- tolerance & dependence
- withdrawal reaction
Warnings/caution:
- ▴hepatic failure
- and▴ renal impairment
- ▴elderly
- ▴respiratory failure
- ▴biliary colic
Interactions:
- ▴other sedating drugs (e.g. antipsychotics, benzodiazepines
Monitoring:
- Explain that nausea usually settles after a few days, but offer an antiemetic (e.g. metoclopramide. Constipation is common however laxative provided
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A patient experienced an attack this afternoon with the following symptom of: sudden attacks of severe, sharp, shooting facial pain that last from a few seconds to about 2 minutes, pain is often described as excruciating, like an electric shock. What is the diagnosis and treatment?
Trigeminal neuralgia
DISCUSS CARBAMAZEPINE CLINICAL PHARM
Indications:
- Seizure prophylaxis in epilepsy
- Trigeminal neuralgia, as a first-line option to control pain and reduce frequency and severity of attacks.
Adverse effect:
- GI upset (e.g. nausea and vomiting)
- neurological effects (Dizziness)
- hypersensitivity
- Antiepileptic hypersensitivity syndrome
- include oedema and hyponatraemia
Warnings/caution:
- ▴pregnancy
- ▴hepatic, ▴renal or ▴cardiac disease toxicity
Contraindications:
- ✗antiepileptic hypersensitivity syndrome
Interactions:
- efficacy of ▴drugs that are metabolised by CYP enzymes (e.g. warfarin)
- adverse effects are increased by ▴CYP inhibitors (e.g. macrolides)
- complex reactions ▴other antiepileptic drugs (e.g. see Lamotrigine)
Monitoring:
- comparing seizure frequency before and after
- and also monitoring nerve pain symptoms
A patient experienced the following: lose consciousness, body goes stiff, limbs jerking, loss of bladder, tongue biting, and difficulty breathing and lasted a few mins. What is the diagnosis and management.
Tonic clonic seziures
DISCUSS VALPORATE CLINICAL PHARM
Drug names: Sodium valporate
Indications:
- Seizure prophylaxis in epilepsy management
- First-line choice for prophylaxis of generalised tonic–clonic seizures, absence seizures, focal seizures
- established convulsive status epilepticus
- Bipolar disorder
Adverse effects:
- GI upset (such as nausea, gastric irritation and diarrhoea
- neurological and psychiatric effects
- thrombocytopenia
- increase in liver enzymes
- hair loss
- severe liver injury, pancreatitis, bone marrow failure, antiepileptic hypersensitivity syndrome
Warnings/cautions:
- ▴hepatic impairment
- ▴severe renal impairment
Contraindications:
- ✗women of child-bearing age
- ✗conception and in the ✗first trimester of pregnancy
- risk of fetal abnormalities
Interactions:
- Risk of toxicity with ▴lamotrigine
- ▴drugs metabolised by cytochrome P450 (CYP) enzymes, such as warfarin
- Adverse effects are increased by ▴CYP inhibitors (e.g. macrolides
- efficacy of antiepileptic drugs is reduced by ▴drugs that lower the seizure threshold
Monitoring
- Warn patients that they may have some indigestion or tummy upset when starting valproate, but that these will settle in a few days and can be reduced by taking tablets with food.
- comparing seizure frequency before and after starting treatment or dose adjustment and toxicity
DISCUSS LAMOTRIGINE CLINICAL PHARM
Indications:
- Seizure prophylaxis in epilepsy
- Lamotrigine is an option for first-line monotherapy or add-on therapy in focal seizures, generalised tonic–clonic seizures and absence seizures.
- Bipolar depression
Adverse effects:
- headache
- drowsiness
- irritability
- blurred vision, dizziness and gastrointestinal symptoms.
- skin rash
- severe hypersensitivity reaction
Warning/caution:
- ▴hypersensitivity to other antiepileptic drugs
- ▴hepatic impairment
- pregnancy increases the overall risk of congenital malformations
Contraindications:
- Active liver disease.
Personal or family history of severe, drug-related, hepatic dysfunction.
Interactions:
- metabolism by glucuronidation
- ▴carbamazepine, ▴phenytoin, ▴oestrogens, ▴rifampicin
- Glucuronidation is inhibited by ▴valproate, causing increase in lamotrigine
Monitoring:
- Treatment efficacy is monitored by comparing seizure frequency before and after starting treatment or dose adjustment. Safety and tolerability are monitored by enquiring about adverse effects.
DISCUSS LEVETIRACETAM CLINICAL PHARM
Indications:
- Seizure prophylaxis in epilepsy
- Levetiracetam is an option for monotherapy or add-on therapy of focal seizures,
- add-on therapy for myoclonic seizures and generalised tonic–clonic seizures if the first agent is insufficient.
Adverse effects:
- Drowsiness
- Weakness
- Dizziness
- Headache
- Mood disturbances
Caution/warning:
- ▴renal impairment
- overall risk of congenital malformation when taken during pregnancy
Interactions:
- few clinically significant interactions
Monitoring:
- Explain to patients that the aim of treatment is to reduce seizure frequency, not to ‘cure’ epilepsy.
- They remember (unless the next dose is imminent, in which case they should just take that one). They should not stop treatment abruptly, as this can cause rebound seizures
DISCUSS BENZODIAZAPINES CLINICAL PHARM
Indications:
- first-line management of seizures and status epilepticus.
- first-line management of alcohol withdrawal reactions.
- sedation for interventional procedures, if general anaesthesia is unnecessary
- short-term treatment of severe, disabling or distressing anxiety or insomnia
Adverse effects:
- drowsiness, sedation and coma
- airway obstruction and death.
- dependence
- withdrawal
Warnings:
- ▴neuromuscular disease
- ▴respiratory impairment
- ▴liver failure
Interactions:
- ▴CYP inhibitors (e.g. amiodarone, diltiazem increase effect
Monitoring:
- When treating insomnia and anxiety, advise your patient that pharmacological therapy is only a short-term measure
- Close monitoring of the patient’s clinical status and vital signs are essential following IV or high-dose oral administration of a benzodiazepine
DISCUSS METOCLOPRAMIDE CLINICAL PHARM
Indications:
- nausea and vomiting
Drug names: metoclopramide, domperidone
Adverse effects:
- diarrhoea
- extrapyramidal syndromes (movement abnormalities,via the same mechanism as antipsychotics
- acute dystonic reaction such as an oculogyric crisis spasmodic deviations of the eyes
- QT-interval prolongation and arrhythmias.
Warnings/caution:
- ▴children and ▴young adults
- ▴hepatic impairment
- ▴intestinal obstruction
- ▴Parkinson’s disease
Contraindications:
- ✗cardiac conduction abnormalities
- ✗neonates
- ✗perforation
Interactions:
- Antipsycotics due to extrapyramidal effects
- ✗dopaminergic agents for Parkinson’s disease,
- drugs that prolong the QT interval (Antipsycotics, SSRIs)
- inhibit cytochrome P450 (CYP) inhibitors (e.g. amiodarone
Monitoring:
- Outline the risk of movement disorders
- Prolonged use is not recommended, if so monitor extrapyramidal symptoms
DISCUSS CYCLIZINE CLINICAL PHARM
Indications:
- Nausea and vomiting
- motion sickness or vertigo
Drug names: cyclizine, cinnarizine, promethazine
Adverse effects:
- drowsiness
- dry throat and mouth
- tachycardia
- palpitations
Warning/cautions:
- ▴hepatic encephalopathy
- ▴prostatic enlargement
Interactions:
- Sedation may be greater when combined with other sedative drugs (e.g. benzodiazepines
- Anticholinergic effects may be more pronounced in patients taking ipratropium
Monitoring:
-Resolution of symptoms is the best guide to efficacy.
A patient diagnosed with schizophrenia has come to the ed with extra muscular movement and eyes looking upwards and he is vomiting. What antiemetic could cause these symptoms that was prescribed in his case?
prochlorperazine - antiemetic
DISCUSS PROCHLORPERAZINE & CHLORPROMAZINE CLINICAL PHARM
Indications:
- Nausea and vomiting, particularly in the palliative care setting.
- Urgent treatment of severe psychomotor agitation that is causing dangerous or violent behaviour
- Schizophrenia
- Bipolar
Drug names: prochlorperazine, haloperidol, chlorpromazine (first gen antipsycotics)
Adverse effects:
- Extrapyramidal effects—movement abnormalities
- acute dystonic reactions
- akathisia is a state of inner restlessness
- neuroleptic malignant syndrome
- erectile dysfunction
- drowsiness, hypotension, QT-interval prolongation
Warning/caution:
- ▴Elderly patients are particularly sensitive
- ▴dementia
- ▴Parkinson’s disease
Interactions:
- ▴drugs that prolong the QT interval (e.g. amiodarone, macrolides).
Monitoring:
- treatment with antipsychotics is control of symptoms
DISCUSS ONDANSETRON CLINICAL PHARM
Indications:
- Antiemetic for chemotherapy, radiotherapy and surgery induced vomiting and nausea.
Adverse effects:
- Constipation
- Feeling hot
- Headache
- Sensation abnormal
- Chest pain
- Hiccupsh
- Hypotension
- Oculogyric crisis
Warnings/caution:
- Adenotonsillar surgery
- Subacute intestinal obstruction
- QT-interval prolongation
Contraindication:
- Congenital long QT syndrome
Interactions:
- Almotriptan
- Aminophylline is predicted to cause hypokalaemia
- Amiodarone
A patient experienced the following: nausea or vomiting, photophobia, unilateral location, moderate or severe pain intensity, pulsating quality, aggravation by routine physical activity, Headache lasting 4 hours 2 times a week. What is the diagnosis and how will you manage it?
- Migrane with aura
- Keep a log of headaches, severity, how long it lasted, frequency, triggers.
- Oral Sumatriptan, antiemetic, Headache lasting 4
- Propranolol as prophylaxis due to frequency
