Nervous system Flashcards
What is the main aim of treatment for epilepsy and other seizure disorders?
to prevent the occurrence of seizures
by maintaining an effective dose of one or more antiepileptic drugs
What is recommended regarding the dosage frequency of antiepileptic drugs?
should be kept as low as possible so patient adheres
.
but if patient has a large dose, may need to give it more frequently to avoid adverse effects associated with high plasma-drug concentration
Why is monotherapy with first or second line antiepileptic drugs preferred?
to reduce the risk of adverse effects and drug interactions that may occur with using multiple drugs
What cautionary advice has been provided by MHRA/CHM regarding switching between different manufacturers’ products of antiepileptic drugs? (2)
Loss of seizure control
and/or worsening of side effects
What should be done if a patient needs to be maintained on a specific manufacturer’s product of antiepileptic drug? (2)
prescribed by brand name
or by using the generic drug name along with the name of the manufacturer.
How should adverse reactions to antiepileptic drugs be reported?
Yellow Card
What should be done if a prescribed antiepileptic drug product is unavailable?
use one from a different manufacturer
Which antiepileptic drugs fall under the category where patients should be maintained on a specific brand? (4)
carbamazepine
phenytoin
phenobarbital
primidone
CP3
Which antiepileptic drugs are listed under the category where the supply of a specific brand is based on clinical judgment? (11)
Valproate
lamotrigine
perampanel
retigabine
rufinamide
clobazam
clonazepam
oxcarbazepine
eslicarbazepine
zonisamide
topiramate
In the risk-based categories of antiepileptic drugs, which category deems it unnecessary to supply a specific brand? (7)
Levetiracetam
lacosamide
tiagabine
gabapentin
pregabalin
ethosuximide
vigabatrin
What risk is associated with ALL antiepileptic drugs regarding suicidal thoughts and behavior?
associated with a small increased risk of suicidal thoughts and behavior.
When should patients seek medical advice regarding symptoms related to suicidal thoughts and behavior after starting antiepileptic treatment?
Immediately
symptoms may occur as early as one week after starting treatment
What precaution should be taken regarding the withdrawal of antiepileptic drugs? (2)
Abrupt withdrawal should be avoided
Reduction in dosage should be gradual
(in the case of barbiturates, withdrawal of the drug may take MONTHS due to the significant risk of SEIZURE RECURRENCE)
What is the recommended approach for withdrawing antiepileptic drugs in patients on multiple medications?
Withdraw one drug at a time
What are the criteria for patients with epilepsy to be able to drive a motor vehicle? (2)
if they have been seizure-free for one year
or have established a 3-year period of asleep attacks without awake attacks
(excluding large goods or passenger carrying vehicles)
What cautionary advice does the DVLA provide regarding driving and medication changes or withdrawal of antiepileptic drugs? (2)
that patients should not drive during medication changes
or withdrawal of antiepileptic drugs
for 6 months
What are the antiepileptic drugs associated with an increased risk of teratogenicity during pregnancy? (6)
Valproate
phenytoin
primidone
phenobarbital
lamotrigine
carbamazepine
What is the highest risk antiepileptic drug associated with congenital malformations and long-term developmental disorders?
Valproate
Can valproate be used in pregnancy? (2)
NO
UNLESS there is no safer alternative
Valproate should not be used during pregnancy or female children, or women who can bear children
What is the recommendation regarding contraception for women of child-bearing potential who are taking antiepileptic drugs?
should be given advice about the need for an effective contraception method to avoid unplanned pregnancy.
What precautionary measure is advised to reduce the risk of neural tube defects during pregnancy?
Folate supplementation
is advised before conception and throughout the first trimester
What is the recommendation for women taking antiepileptic monotherapy regarding breastfeeding?
Women taking antiepileptic monotherapy should generally be encouraged to breastfeed
(but specialist advice should be sought if needed)
What should infants be monitored for if their mothers are taking antiepileptic drugs and breastfeeding? (4)
sedation
feeding difficulties
adequate weight gain
developmental milestones
What precaution should be taken to prevent withdrawal effects in infants if a mother suddenly stops breastfeeding while taking antiepileptic drugs?
important to avoid abrupt cessation of breastfeeding
When should serum-drug concentration monitoring be undertaken in breastfed infants?
if suspected adverse reactions develop.
What is antiepileptic hypersensitivity syndrome, and which antiepileptic drugs are associated with it? (2)
Antiepileptic hypersensitivity syndrome is a rare but potentially fatal syndrome associated with some antiepileptic drugs
including carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide.
What are simple partial seizures?
seizures where the individual remains fully conscious throughout
Describe complex partial seizures.
seizures where the individual loses awareness
and cannot remember what happened after the seizure has passed.
What characterizes absence seizures?
Absence seizures cause the person to lose awareness of their surroundings
typically for up to 15 seconds.
What physical manifestations occur during myoclonic seizures?
Myoclonic seizures cause jerking or twitching movements
in the arms, legs, or upper body
How do tonic-clonic seizures progress? (3)
Tonic-clonic seizures have two stages and last a few minutes
Initially, the body becomes stiff (tonic phase)
followed by twitching of the arms and legs (clonic phase).
What is considered a medical emergency in terms of seizure duration? (2)
Any seizure lasting longer than 30 minutes
or a series of seizures without regaining consciousness in between.
What is the therapeutic range for Carbamazepine?
4 to 12mg/L (20 to 50 micromol/litre).
What are some warning signs associated with Carbamazepine use? (5)
toxicity symptoms such as incoordination, blurred vision, double vision, drowsiness, nystagmus, ataxia, arrhythmias, nausea & vomiting, diarrhea, and hyponatremia
blood disorders (fever, sore throat, unexplained bruising or bleeding)
skin disorders (mouth ulcers, rash)
hepatic disorders (severe GI upset, fatigue, jaundice, dark urine)
Antiepileptic Hypersensitivity Syndrome (fever, rash, swollen lymph nodes).
How should Carbamazepine therapy be monitored? (4)
plasma concentration (after 2 weeks to ensure it’s within the therapeutic range)
full blood count
renal function
hepatic function
Why may the dose of Carbamazepine be different in those with impaired liver disease? (2)
as their metabolism of Carbamazepine is impaired
so the dose may need to be increased accordingly
How should doses of Carbamazepine be adjusted during pregnancy?
based on plasma-concentration monitoring.
What are some drug interactions associated with Carbamazepine? (4)
increased plasma concentration with acetazolamide, cimetidine, clarithromycin, and erythromycin.
Decreased plasma concentration can occur with phenytoin, rifabutin, and St. John’s Wort.
It reduces the plasma concentration of antipsychotics, corticosteroids, coumarins, eplerenone, estrogens, progestogens, and simvastatin.
Additionally, there’s a possible increased risk of convulsions when given with orlistat (this applies to all antiepileptics)
What are the side effects associated with IV infusion of fosphenytoin?
severe cardiovascular reactions (including asystole, ventricular fibrillation, and cardiac arrest)
Hypotension, bradycardia, and heart block have also been reported
What monitoring and precautions are recommended when administering IV fosphenytoin? (2)
DURING infusion:
monitor heart rate, blood pressure, and respiratory function
AFTER infusion:
continue monitoring for at least 30 minutes
What should be done if hypotension occurs when administering IV fosphenytoin? (2)
reduce its infusion rate
or stop it completely
What type of individuals should we reduce the dose or infusion rate of IV fosphenytoin in? (3)
elderly
renal impairment
hepatic imapirment
Which drugs can lead to an increased plasma concentration of Carbamazepine? (4)
Acetazolamide
cimetidine
clarithromycin
erythromycin
What drugs can lead to DECREASED plasma concentration of carbamazepine? (3)
Phenytoin
rifabutin
St. John’s Wort
Which types of medications does Carbamazepine reduce the plasma concentration of? (7)
antipsychotics
corticosteroids
coumarins
eplerenone
estrogens
progestogens
simvastatin
What is the potential risk when antiepileptics are administered with orlistat?
increased risk of convulsions
What safety concerns are associated with high doses of gabapentin oral solution in adolescents or adults with low body weight (39–50 kg)?
high dose means they may INGEST LEVELS of propylene glycol, acesulfame K, and saccharin sodium
THAT EXCEED the DAILY INTAKE limits recommended by the World Health Organization (WHO)
What symptoms in relation to blood disorders should patients and their carers be alert for when taking LAMOTRIGINE?
symptoms of bone-marrow failure
such as anaemia, bruising, or infection
What serious skin reactions can develop with lamotrigine, and within what timeframe? (2)
Stevens-Johnson syndrome and toxic epidermal necrolysis
can develop within the first 8 weeks of taking lamotrigine.
What factors are associated with an increased risk of serious skin reactions with lamotrigine?
taking valproate at the same time
starting off on a higher initial dose than recommended
rapid dose increases
When should withdrawal of lamotrigine be considered?
if rash
or signs of hypersensitivity syndrome develop
What is the therapeutic range for phenytoin?
10 to 20mg/L (or 40 to 80 micromol/litre)
What is the dose equivalence between phenytoin sodium and phenytoin base?
100mg of phenytoin sodium to 92mg of phenytoin base
is equivalent in therapeutic effect
Why is it important to consider the difference in phenytoin content when switching formulations?
because the difference between phenytoin sodium and phenytoin base may be clinically significant.
What are some warning signs that patients taking phenytoin should report to their doctor immediately?
nystagmus, double vision, slurred speech, ataxia, confusion, hyperglycemia, rash, toxic epidermal necrolysis, jaundice, GI pain, dark urine, bleeding, bruising, fever, mouth ulcers, sore throat, suicidal thoughts, and low vitamin D levels (which may lead to rickets in children or osteomalacia in adults) to their doctor immediately.
Which drugs can lead to increased plasma concentrations of phenytoin?
amiodarone, chloramphenicol, cimetidine, disulfiram, diltiazem, fluconazole, fluoxetine, miconazole, topiramate, trimethoprim, metronidazole, clarithromycin, and telithromycin.
Which drugs can reduce plasma concentrations of phenytoin?
Rifamycins, St. John’s Wort, theophylline, itraconazole, and ciclosporin
What should patients be monitored for during sodium valproate treatment?
patients should be monitored for liver dysfunction
especially in the first 6 months of treatment, particularly if they are on multiple antiepileptic therapies
liver changes usually transient- monitor every 6 months until return to normal
When should treatment with sodium valproate be discontinued?
abnormally prolonged prothrombin time persists
or if signs of toxicity such as persistent vomiting, abdominal pain, anorexia, jaundice, and loss of seizure control occur.
What adverse ocular effect is associated with topiramate?
acute myopia (short-sightedness) with secondary angle-closure glaucoma, typically occurring within 1 month of starting treatment.
Fluid build-up resulting in anterior displacement of the lens and iris has also been reported.
What actions should be taken if raised intra-ocular pressure occurs in a patient taking topiramate? (3)
tpiramate should be stopped as rapidly as feasible
specialist ophthalmological advice should be sought.
Appropriate measures to reduce intra-ocular pressure should be used
What adverse effect is associated with vigabatrin?
Visual field defects
Any new visual symptoms should be reported and reviewed urgently by an ophthalmologist
Test visual field BEFORE starting treatment and at 6-month intervals
If develop symtoms= withdraw gradually
The onset of symptoms can vary from 1 month to several years after starting treatment, and visual problems usually persist despite discontinuation.
How should benzodiazepines for anaesthesia be administered?
should only be administered by or under the direct supervision of experienced personnel
with adequate training in anaesthesia and airway management.
What should benzodiazepines, Z-drugs, Chlomethiazole, promethazine, and melatonin be used for?
as hypnotics
Which medications are categorized as anxiolytics? (4)
benzodiazepines
buspirone
meprobamate
barbiturates
How can the effects of benzodiazepine dependence and withdrawal be minimized?
Withdrawal symptoms include insomnia, anxiety, loss of body weight and appetite, tremor, and perspiration
Develop up to 3 WEEKS after stopping a LONG-acting drug benzodiazepine
Develop DAYS after stopping a SHORT-acting one.
Best to do gradual withdrawal: minimizes effects such as confusion, convulsions, and toxic psychosis.
For which conditions are intermediate-acting barbiturates recommended?
only recommended for severe intractable insomnia, in patients already taking barbiturates
Who should we avoid barbiturates in?
elderly
What are the indications for benzodiazepine use?
indicated for the short-term relief (two to four weeks only) of anxiety that is severe or disabling, occurring with or without insomnia.
They should be used to treat insomnia only when it is severe, disabling, or causing the patient extreme distress.
Which benzodiazepines are classified as short-acting? (5)
Temazepam
Oxazepam
Loprazolam
Lormetazepam
Lorazepam
(TOLLL)
What side effects are associated with benzodiazepine overdose? (5)
- drowsiness
- ataxia
- dysarthria
- nystagmus
- and occasionally respiratory depression and coma
Ataxia means without coordination. People with ataxia lose muscle control in their arms and legs
Dysarthria is where you have difficulty speaking because the muscles you use for speech are weak.
Nystagmus is a rhythmical, repetitive and involuntary movement of the eyes. It is usually from side to side, but sometimes up and down or in a circular motion.
Respiratory depression (hypoventilation) is when you breathe too slowly or shallowly, preventing proper gas exchange in your lungs
how can benzodiazepine overdose be treated?
Activated charcoal
can be given within 1 hour of ingesting a significant quantity of benzodiazepine
provided the patient is awake and the airway is protected
Why should benzodiazepines and Z-drugs be avoided in the elderly?
due to an increased risk of confusion leading to falls and injury.
What CNS stimulants are used for the management of ADHD?
Methylphenidate and atomoxetine
(Dexamfetamine and lisdexamfetamine are alternatives in children who do not respond to these drugs)
What should be monitored during atomoxetine therapy?
Pulse, blood pressure, psychiatric symptoms, appetite, weight, and height
should be recorded at the initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.
ADDITIONALLY, monitoring for the appearance or worsening of anxiety, depression, or tics is advised, especially in patients with a history of seizures.
What rare risk is associated with atomoxetine?
hepatic disorders
Prompt medical attention should be sought in case of abdominal pain, unexplained nausea, malaise, darkening of the urine, or jaundice.
Is there a risk of suicidal ideation with atomexetine?
Yes
There is a risk of suicidal thoughts and behavior
Patients should report any clinical worsening, suicidal thoughts or behavior, irritability, agitation, or depression to their GP.
What action should be taken if tics occur during dexamfetamine and lisdexamfetamine therapy
should be discontinued
What is the recommended duration of treatment for bipolar disorder after the last manic episode?
Treatment should be long term
Treat for at least two years from the last manic episode,
But if have risk factors for relapse, treat for up to 5 years
What class of drug may be heloful in the initial management of agitation in bipolar disorder?
Acute benzodiazepines
Which atypical antipsychotic drugs are useful in acute episodes of mania and hypomania?
olanzapine
quetiapine
risperidone
What is the narrow therapeutic range for lithium?
The narrow therapeutic range for lithium is 0.4 to 1 mmol/L
with the lower end recommended for maintenance and elderly patients,
and the higher end 0.8 to 1 mmol/L for acute episodes of mania and relapse patients.
What are some warning signs of lithium toxicity that require immediate reporting and treatment withdrawal? (8)
include serum concentration over 2 mmol/L
increasing gastrointestinal disturbances (vomiting, diarrhea)
visual disturbances (blurred vision)
CNS disturbances (drowsiness, unsteadiness, confusion)
tremors
signs and symptoms of hypothyroidism
signs and symptoms of renal dysfunction
and signs and symptoms of benign intracranial hypertension (persistent headache and visual disturbance).
How often should serum lithium concentration be monitored?
weekly initially
then every 3 months once the dose becomes stable.
How frequently should renal function be monitored in patients taking lithium?
every 6 months
What is the recommended frequency for monitoring cardiac function in patients on lithium therapy?
every 6 months
How often should thyroid function be monitored in patients taking lithium?
every 6 months
What caution should be exercised regarding driving and skilled tasks for patients on lithium therapy?
Patients may experience impaired performance of skilled tasks, such as driving or operating machinery.
What interactions increase the risk of toxicity with lithium? (10)
ACE inhibitors
angiotensin-II receptor antagonists
loop diuretics
thiazides and related diuretics
NSAIDs
potassium-sparing diuretics
aldosterone antagonists
metronidazole
SSRIs
tricyclics
What drug interacts with lithium to increase the risk of ventricular arrhythmias?
amiodarone
Which medications increase the risk of neurotoxicity when taken with lithium? (5)
methyldopa
phenytoin
carbamazepine
diltiazem
verapamil
What precaution should be taken when changing the preparation of lithium?
When changing the preparation of lithium
the** same precautions as the initiation of treatment** should be observed
due to the varying bioavailability of different preparations.
What should be given to patients on initiation of lithium treatment?
A lithium treatment pack
Why should patients be kept on the same brand of lithium?
to maintain consistency in dosage and bioavailability
How can lithium toxicity be exacerbated?
by sodium depletion
important to maintain a constant and adequate intake of salt and water, especially during infections or hot weather.
What substances should be avoided while taking lithium?
NSAIDs (nonsteroidal anti-inflammatory drugs)
alcohol
What is the risk of stopping lithium suddenly?
Stopping lithium suddenly can increase the risk of relapse
should only be done under the guidance of a doctor.
What are the major classes of antidepressant drugs (3)
tricyclic and related antidepressants
selective serotonin reuptake inhibitors (SSRIs)
monoamine oxidase inhibitors (MAOIs)
Which class of antidepressants is considered first-line indepression due to better tolerance and safety in overdose?
Selective serotonin reuptake inhibitors (SSRIs)
Who are tricyclic antidepressants not effective in treating depression in
children
What is a risk associated with MAOIs?
MAOIs have dangerous interactions with some foods and drugs.
Why should St John’s Wort not be recommended for depression?
an enzyme inducer and interacts with many drugs
What risk is associated with all types of antidepressant therapy?
Hyponatremia (usually in the elderly) is a risk associated with all types of antidepressants, with SSRIs posing a higher frequency.
What are symptoms of hyponatremia? (3)
drowsiness
confusion
convulsions
What population is particularly monitored for suicidal behavior when undergoing antidepressant therapy?
in children, young adults, and patients with a history of suicidal behavior
particularly at the beginning of treatment or if the dose is changed.
What are the three main areas of symptoms in serotonin syndrome? (3)
neuromuscular hyperactivity (tremor, hyperreflexia, clonus, myoclonus, rigidity)
autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhea)
altered mental state (agitation, confusion, mania).
Why are monoamine oxidase inhibitors (MAOIs) less common than tricyclics or SSRIs?
due to their dietary and drug interactions.
What dietary precautions should patients taking MAOIs follow? (4)
should eat only fresh foods, avoid stale or “going off” food
avoid foods containing tyramine, such as mature cheese, pickled herring, broad bean pods
avoid certain food extracts like Bovril®, Oxo®, and Marmite®
They should also avoid alcoholic drinks or low-alcohol drinks.
Why should other antidepressants not be started for 2 weeks after stopping MAOIs?
to avoid the risk of serotonergic adverse effects.
What are the potential withdrawal symptoms of MAOIs? (11)
agitation
irritability
ataxia
movement disorders
insomnia
drowsiness
vivid dreams
cognitive impairment
slowed speech
hallucinations
paranoid delusions.
How should cessation of MAOIs be managed?
by slowly tapering the dose over at least 4 weeks
Which selective serotonin re-uptake inhibitors (SSRIs) are not recommended for individuals under 18? (6)
Citalopram
escitalopram
paroxetine
sertraline
mirtazapine
venlafaxine
Which SSRI has been shown to be effective for use in children and adolescents?
Only fluoxetine
What are some cautions associated with SSRIs? (7)
epilepsy (avoid if poorly controlled, discontinue if convulsions develop)
cardiac disease
diabetes mellitus
susceptibility to angle-closure glaucoma
history of mania
history of bleeding disorders (especially gastrointestinal bleeding)
if being used with other drugs that increase the risk of bleeding.
What are symptoms of poisoning from an SSRI overdose? (8)
nausea
vomiting
agitation
tremor
nystagmus
drowsiness
sinus tachycardia
convulsions
Rarely, severe poisoning results in the serotonin syndrome, with marked neuropsychiatric effects, neuromuscular hyperactivity, and autonomic instability
What are the most common symptoms of abrupt withdrawal from certain antidepressants? (11)
Gastro-intestinal disturbances
headache
anxiety
dizziness
paraesthesia
electric shock sensation in the head, neck, and spine
tinnitus
sleep disturbances
fatigue
influenza-like symptoms
sweating
Paresthesia is the feeling of tingling, numbness or “pins and needles.”
How long should the dose of antidepressants be tapered over to avoid withdrawal effects?
over at least 4 weeks
Which antidepressants are associated with a higher risk of withdrawal effects? (2)
Paroxetine
venlafaxine
Who should we use tricyclic and related antidepressants with caution in? (6)
cardiovascular disease
hyperthyroidism
prostatic hypertrophy
chronic constipation
urinary retention
glaucoma
Elderly patients are more susceptible to adverse effects.
Are tricyclic antidepressants effective for treating depression in children?
No
What is one rare side effect of antidepressants that involves the liver?
Hepatotoxicity, or hepatic injury
How should patients be advised regarding the risk of hepatic side effects associated with antidepressants?
Patients should be instructed to seek immediate medical attention if symptoms such as dark urine, light-colored stools, jaundice, bruising, fatigue, abdominal pain, or pruritus develop.
Should we test liver function before starting antidepressant treatment?
Yes, to assess the risk of hepatotoxicity.
What symptoms do antipsychotic drugs relieve? (3)
thought disorder
hallucinations
delusions
What may atypical antipsychotics be better for?
negative symptoms such as apathy and social withdrawal.
What precautions should be taken when prescribing doses of antipsychotic drugs above the BNF upper limit?
Consider adjuvant therapy and newer or second-generation antipsychotic drugs such as clozapine
Bear in mind risk factors, including obesity, especially in older patients, particularly those over 70.
Consider potential for drug interactions
Carry out ECG to exclude abnormalities such as prolonged QT interval; repeat ECG periodically and reduce dose if prolonged QT interval or other adverse cardiac abnormality develops
Increase dose slowly and not more often than once weekly
Carry out regular pulse, blood pressure, and temperature checks; ensure that the patient maintains adequate fluid intake.
Consider high-dose therapy for a limited period and review regularly; abandon if no improvement after 3 months (return to standard dosage).
What should be done if adverse cardiac abnormalities develop during high-dose therapy of antipsychotic drugs?
the dose should be reduced
and periodic ECG should be repeated to monitor cardiac function.
Why should emergency intramuscular (IM) doses of antipsychotic drugs be lower than the corresponding oral doses?
due to the absence of the first-pass effect.
What is the recommended frequency for reviewing the dose of** emergency **antipsychotic treatment?
at least daily
What risks are associated with the use of antipsychotic drugs in elderly patients with dementia?
an increased risk of mortality and stroke or transient ischaemic attack
also particularly susceptible to postural hypotension and hyper- and hypothermia in hot or cold weather.
What precautions should be taken when prescribing antipsychotic drugs to elderly patients?
avoid in mild to moderate cases
Initial doses in elderly patients should be reduced to HALF the adult dose OR LESS
Treatment should be reviewed regularly.
Which atypical antipsychotic drug is licensed for patients over 65, and for how long should it be used before review?
Risperidone
It should be used for a maximum of 6 weeks before review.
What are the symptoms of acute pseudoparkinsonism, and how can it be treated?
The symptoms of acute pseudoparkinsonism include tremor or rigidity.
It can be treated with antimuscarinic drugs, such as procyclidine.
What is Pseudoparkinsonism?
a reaction to medications that imitates the symptoms and appearance of Parkinson’s disease.
How can acute dystonia, characterized by abnormal face and body movements, be treated?
can be treated with antimuscarinic drugs, such as procyclidine.
What is acute akathisia, and how can it be managed?
a feeling of restlessness with a desire to move
develops soon after starting an antipsychotic or increasing its dose, or switching to a high-potency medication
Can be managed by either discontinuing treatment or use different antipsychotic.
What is tardive dyskinesia, and when does it usually develop?
rhythmic, involuntary movements of the tongue, face, and jaw
usually develops on long-term therapy with antipsychotic drugs.
How can chronic tardive dyskinesia be managed?
may be irreversible upon withdrawing therapy
It’s worth switching the patient to an atypical antipsychotic.
Tardive dyskinesia (TD) is a condition where your face, body or both make sudden, irregular movements which you cannot control
What is hyperprolactinemia, and which antipsychotic drugs commonly cause it?
is an increase in prolactin concentration caused by both first- and second-generation antipsychotic drugs.
It’s common with risperidone and amisulpride.
What are the symptoms of hyperprolactinemia? (5)
sexual dysfunction
reduced bone mineral density
menstrual disturbances
breast enlargement
galactorrhea
galactorrhea: excessive or inappropriate production of milk.
Which antipsychotic drugs are commonly associated with sexual dysfunction? (2)
Haloperidol
risperidone
What are the cardiovascular risks associated with antipsychotic drugs?
with doses exceeding the recommended maximum : QT-interval prolongation can occur
leading to side-effects such as tachycardia, arrhythmias, and hypotension.
In severe cases, sudden death can occur.
Which antipsychotic drugs are particularly associated with hyperglycemia, weight gain, and diabetes? (4)
Clozapine
olanzapine
risperidone
quetiapine
corq
What antipsychotic drugs can cause hypotension and interference with temperature regulation? (3)
clozapine
chlorpromazine
quetiapine
hypotension can lead to falls, post hyoptension= cause syncope
ccq
What monitoring is required for patients taking antipsychotic drugs?
Full blood count, urea and electrolytes, and liver function tests are required at the start of therapy, and then annually thereafter.
Blood lipids and weight should be measured at baseline, at 3 months, and then yearly (patients taking clozapine or olanzapine require more frequent monitoring).
Fasting blood glucose should be measured at baseline, at 4–6 months, and then yearly (patients taking clozapine or olanzapine require more frequent monitoring).
Blood pressure monitoring is advised before starting therapy and frequently during dose titration of antipsychotic drugs.
ECG may be required, particularly with cardiovascular risk factors or if a personal history of cardiovascular disease exists.
Prolactin concentration should be monitored at the start of therapy, at 6 months, and then yearly.
Patients with schizophrenia should have physical health monitoring, including cardiovascular disease risk assessment, at least once per year.
What are some adverse reactions associated with chlorpromazine?
Acute dystonic reactions such as facial and skeletal muscle spasms and oculogyric crisis
especially in young children and women
An acute dystonic reaction is characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures.
Oculogyric crises are defined as spasmodic movements of the eyeballs into a fixed position, usually upwards.
How should chlorpromazine be handled to prevent contact sensitization?
Avoid direct contact with chlorpromazine
(tablets should not be crushed, and solutions should be handled with care)
Why is ECG monitoring recommended before and during treatment with pimozide?
It’s recommended due to the risk of sudden unexplained death.
Patients should also have an annual ECG
pimozide should not be given with other antipsychotic drugs, tricyclic antidepressants, or other drugs which prolong the QT interval.
If the QT interval is prolonged, treatment should be reviewed.
What is the major concern associated with clozapine use?
Agranulocytosis
fatal blood disorder
What precautions should be taken before starting clozapine treatment regarding blood counts?
Blood counts must be normal before starting treatment.
What symptoms should patients on clozapine be vigilant about and report immediately?
Patients should report immediately symptoms of infection, especially influenza-like illness.
What are the risks associated with clozapine regarding myocarditis and cardiomyopathy?
There’s a risk of fatal myocarditis and cardiomyopathy.
What actions should be taken if myocarditis or cardiomyopathy is suspected in a patient taking clozapine?
Clozapine should be stopped, and the patient should be evaluated urgently by a cardiologist.
What should be done if patient develops persistent tachycardia, in the first 2 months of clozapine treatment?
do prompt observations for other indicators for myocarditis or cardiomyopathy.
Myocarditis is inflammation of the heart muscle (myocardium). The inflammation can reduce the heart’s ability to pump blood.
cardiomyopathy:general term for diseases of the heart: chambers have become stretched, thickened or stiff.
What should be done if clozapine-induced myocarditis or cardiomyopathy is confirmed?
Clozapine should be discontinued permanently.
What are the risks associated with clozapine regarding intestinal obstruction? (4)
constipation
intestinal obstruction
fecal impaction
fatal paralytic ileus.
Paralytic ileus is the condition where the motor activity of the bowel is impaired, usually without the presence of a physical obstruction.
A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in people who are constipated for a long time.
In which patient population should clozapine be used with caution due to the risk of intestinal obstruction?
Patients receiving drugs that may cause constipation (e.g., antimuscarinic drugs)
or those with a history of colonic disease or lower abdominal surgery.
How can hypersalivation associated with clozapine treatment be managed?
It can be treated with hyoscine hydrobromide
(provided that the patient is not at risk from the additive antimuscarinic side-effects of hyoscine and clozapine)
What should be monitored in patients receiving clozapine, especially in relation to its side effects?
intestinal obstruction risk, hypersalivation, and other potential adverse effects.
What are some risks associated with olanzapine use regarding CNS and respiratory depression?
There’s an increased risk, especially in patients also receiving a benzodiazepine.
How long should vital signs be monitored after intramuscular injection of olanzapine, especially when administered with benzodiazepines?
Blood pressure, pulse, and respiratory rate should be monitored for at least 4 hours after intramuscular injection.
At least one hour should be left between administration of IM olanzapine and parenteral benzodiazepines.
What is the primary cause of Parkinson’s disease symptoms?
The progressive degeneration of neurons in the substantia nigra leading to a deficiency of the neurotransmitter dopamine.
How does drug therapy impact Parkinson’s disease progression?
Drug therapy does not prevent disease progression, but it improves most patients’ quality of life.
What are some examples of dopaminergic drugs used in Parkinson’s disease treatment?
Levodopa, ropinirole, and rotigotine
they active dopamine receptors
What potential adverse effect should be monitored for in patients taking dopaminergic drugs?
Impulse control disorders such as pathological gambling, binge eating, and hypersexuality.
How should impulse control disorder symptoms be managed in patients taking dopaminergic drugs?
drug should be withdrawn
or the dose reduced until the symptoms resolve.
What caution should be exercised regarding driving in patients taking dopaminergic drugs?
Patients may experience sudden onset of sleep or excessive daytime sleepiness, so caution should be exercised when driving or operating machinery.
What advice should be given to patients regarding sleep behavior when taking dopaminergic drugs?
Patients should be counseled on improving sleep behavior to mitigate the risk of sudden onset of sleep or excessive daytime sleepiness.
When are hypotensive reactions most likely to occur in patients taking dopaminergic drugs?
during the first few days of treatment.
How can healthcare providers screen for potential fibrotic reactions before starting treatment with ergot derivatives? (3)
Conduct an ECG before treatment
measure the erythrocyte sedimentation rate
serum creatinine
obtain a chest X-ray
An ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) should only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist.
What symptoms should patients be monitored for when taking ergot-derived dopamine-receptor agonists? (5)
dyspnea
persistent cough
chest pain
cardiac failure
abdominal pain or tenderness.
What considerations should be made regarding dose equivalence and conversion for pramipexole?
Doses and strengths are stated in terms of pramipexole (base).
How much pramipexole base is equivalent to 125 micrograms of pramipexole dihydrochloride monohydrate salt?
88 micrograms of pramipexole base is equivalent to 125 micrograms of pramipexole dihydrochloride monohydrate salt.
How much pramipexole base is equivalent to 250 micrograms of pramipexole dihydrochloride monohydrate salt?
180 micrograms of pramipexole base is equivalent to 250 micrograms of pramipexole dihydrochloride monohydrate salt.
How much pramipexole base is equivalent to 500 micrograms of pramipexole dihydrochloride monohydrate salt?
350 micrograms of pramipexole base is equivalent to 500 micrograms of pramipexole dihydrochloride monohydrate salt.
How much pramipexole base is equivalent to 1 mg of pramipexole dihydrochloride monohydrate salt?
700 micrograms of pramipexole base is equivalent to 1 mg of pramipexole dihydrochloride monohydrate salt.
Why is it important to identify the cause of nausea and vertigo?
It’s important to identify the cause (e.g., diabetic ketoacidosis, digoxin or antiepileptic overdose) to prevent complications.
How is nausea in the first trimester of pregnancy typically managed?
Nausea in the first trimester is generally mild and does not require drug therapy.
However, if vomiting is severe, short-term treatment with an antihistamine such as promethazine may be required.
(Prochlorperazine or metoclopramide are alternatives)
What is the preferred treatment for motion sickness?
It is ideal to prevent motion sickness rather than treat nausea or vomiting.
The most effective drug is hyoscine hydrobromide.
For children over 10, a transdermal patch provides prolonged activity.
If a sedative effect is desired, cyclizine or cinnarizine is preferred.
What is the licensed treatment for Ménière’s disease regarding vertigo, tinnitus, and hearing loss?
Betahistine
What advantage does domperidone have over metoclopramide and phenothiazines in terms of side effects?
Domperidone does not readily cross the blood-brain barrier
making it less likely to cause central side effects such as sedation and dystonic reactions.
acute dystonic reaction is characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures.
phenothiazine antipsychotics are: prochlorperazine, chlopramizne
What risk is associated with domperidone regarding cardiac side-effects?
has an increased risk of serious cardiac side-effects.
How should domperidone be used to mitigate the risk of cardiac side-effects?
should only be used for the relief of the symptoms of nausea and vomiting
at the lowest effective dose
for the shortest possible duration (maximum duration should not exceed 1 week).
In which conditions is domperidone contraindicated?
Domperidone is contraindicated for use in conditions where cardiac conduction is impaired, or there is underlying cardiac disease:
when administered concomitantly
with drugs that prolong the QT interval or potent CYP3A4 inhibitors, and in severe hepatic impairment.
What is the recommended dose of domperidone for adults and adolescents over 12 years and over 35 kg?
The recommended dose is 10 mg up to 3 times daily.
What is the recommended dose of domperidone for children under 35 kg?
The recommended dose is 250 micrograms/kg up to 3 times daily.
How should oral liquid formulations of domperidone be administered to ensure dose accuracy?
Oral liquid formulations should be given via an appropriately designed, graduated oral syringe to ensure dose accuracy.
What are the indications for aspirin use? (4)
headache
transient musculoskeletal pain, dysmenorrhea
pyrexia
What is a common problem associated with aspirin use, and how can it be minimized? (2)
Gastric irritation
can be minimized by taking the dose after food.
What are the similarities and differences between paracetamol and aspirin in terms of efficacy and side effects?
Paracetamol is similar in efficacy to aspirin but lacks demonstrable anti-inflammatory activity.
less irritant to the stomach, making it generally preferred to aspirin,* especially in the elderly.*
When may nefopam be considered for pain relief?
in the relief of persistent pain unresponsive to other non-opioid analgesics
What potential side effects should be monitored for with nefopam use?
Antimuscarinic side effects
Why might paracetamol be preferred over NSAIDs, especially in the elderly?
Paracetamol is often preferred over NSAIDs, especially in the elderly, due to its lower risk of gastrointestinal side effects.
In what circumstances might COX2 inhibitors be used in pain management?
in patients at high risk of developing serious gastrointestinal side effects from NSAIDs.
What is the recommended ibuprofen dose for post-immunisation pyrexia in infants aged 2–3 months?
50 mg as a single dose
(repeated once after 6 hours if necessary)
What are the recommended ibuprofen doses by mouth for children aged 1–3 months?
5 mg/kg four times daily (QDS).
What is the recommended paracetamol dose for post-immunisation pyrexia in infants aged 2–4 months?
60 mg as a single dose
repeated once after 4–6 hours if necessary (max 4 doses in 24 hours).
What are the recommended paracetamol doses by mouth for children aged 3–6 months?
60 mg four times daily (QDS).
When does paracetamol pose an increased risk of toxicity? (2)
body-weight under 50 kg
those with risk factors for hepatotoxicity.
At what age is paracetamol not licensed for use by mouth in children?
in children under 2 months
What is the recommended ibuprofen dose by mouth for children aged 7–10 years?
200 mg three times daily (TDS).
What is the maximum recommended ibuprofen dose for children aged 12 and over?
Initially 300–400 mg four times daily (QDS),
increased if necessary to a maximum of 600 mg four times daily (QDS).
What are the warning signs associated with opiate use that should be reported to a GP immediately? (7)
respiratory depression (difficulty breathing)
bradycardia/hypotension (feeling faint, dizziness)
extreme sleepiness
reduced concentration or confusion (not able to think, walk or talk normally)
cyanosis (of lips, ears, nose),
vivid dreams, hallucinations or nightmares, convulsions
pinpoint pupils
Cyanosis refers to a bluish-purple hue to the skin.
What psychological behaviors indicate opiate dependence? (3)
craving
compulsive use
continuing to be used by patient despire the harm it may be causing them
When does opiate withdrawal occur? What are its signs?
It occurs when the drug is stopped suddenly or when the dose is tapered rapidly.
Signs of withdrawal include sweating, restlessness, tremor, increase in normal pain, diarrhea, nausea/vomiting, and anxiety.
A patient is said to be tolerant to their old opiod dose. What does this mean?
The patients dose has to be increased to achieve the same therapeutic effect.
What aspects of patients should be monitored when administering opiates? (2)
Pain
sedation levels
What are some interactions to be aware of when prescribing opiates?
Opiods + alcohol = enhanced hypotensive and sedative effects
Tramadol (opiod) + coumarins= tramadol enhances the anticoagulant effect of coumarin
Rifampicin + fentanyl/ morphine/codeine/ methadone- alfentanil= reduction in the effect of these opioids
Opiates+ MAOIs= possible CNS excitation or depression (hypertension or hypotension)
What precautions should be taken regarding dose adjustments of opiates?
Dose increases should not exceed 50% of the previous dose
and treatment should not be stopped suddenly.
What is the recommended dose of opioid for breakthrough pain in relation to the total daily dose?
1/10th to 1/6th of the total daily dose.
According to the analgesic ladder, what are the three steps in pain management?
Non-opioid analgesics such as aspirin, paracetamol, and NSAIDs.
Weak opioids such as codeine, dihydrocodeine, and meptazinol.
Strong opioids such as morphine, buprenorphine, diamorphine, fentanyl, oxycodone, tapentadol, and tramadol.
What variation in metabolism occurs with codeine, and how does it affect patient response? (3)
Codeine has to be metabolised by the lvier to produce morphine, so it can exert its therapeutic effects
Some people quickly metabolise the codeine, lots of morpine produced and have increased risk of morphine toxicity
On the other hand, some people have poor codeine metabolizers and thus may experience reduced therapeutic effects.
Ultra-rapid codeine metabolizers (CYP2D6 ultra-rapid metabolizers)
Who are the contraindicated populations for codeine use? (4)
Children younger than 12 years old.
Patients of any age known to be CYP2D6 ultra-rapid metabolizers.
Breastfeeding mothers.
All children under 18 who undergo surgery of tonsils or adenoids for sleep apnea.
All children under 18 with respiratory problems.
What precautions should be taken when using transdermal fentanyl patches in patients?
Monitor patients if fever is present, as increased absorption is possible
Avoid exposing the application site to external heat, such as a hot bath or sauna, as it may also increase absorption.
Due to the long duration of action, patients who have had severe side effects should be monitored for up to 24 hours after patch removal
What is the significant risk associated with fentanyl use, particularly in opioid-naïve patients?
risk of fatal respiratory depression, particularly in opioid-naïve patients
recommended to use fentanyl patches only in opioid-tolerant patients.
What action should patients and caregivers take if certain symptoms occur while using fentanyl patches?
Patches should be removed immediately if breathing difficulties, marked drowsiness, confusion, dizziness, or impaired speech occur.
Patients and caregivers should seek prompt medical attention.
What causes neuropathic pain, and what are some examples of conditions associated with it?
caused by result of damage to neural tissue.
Examples of conditions associated with neuropathic pain include phantom limb pain, compression neuropathies, and peripheral neuropathies
How is neuropathic pain generally managed?
a tricyclic antidepressant or with certain antiepileptic drugs, such as amitriptyline/ nortriptyline and pregabalin/ gabapentin
Nortriptyline may be better tolerated than amitriptyline
C apsaicin is licensed for neuropathic pain but what limitation does it have?
its use may be limited due to the intense burning sensation during initial treatment.
What are the commonly used medications for acute treatment of migraine?
Aspirin, paracetamol, or a NSAID
(pt may also require anti- sickness meds alongside)
When might 5HT1-receptor agonists (‘triptans’) be used in migraine treatment?
If simple analgesics are not helping
Why are ergot alkaloids rarely used in migraine treatment?
less suitable for prescribing compared to other options.
What precaution should be taken regarding ergotamine treatment and peripheral vasospasm?
Stop ergotamine treatment immediately if numbness or tingling of extremities develops and contact a doctor.
can generally be treated in a community setting
Long-acting benzodiazepines are used to reduce alcohol withdrawal symptoms.
What are the potential risks associated with alcohol withdrawal in severely dependent patients? (4)
Without inpatient medical support, withdrawal in severely dependent patients may lead to:
- seizures
- delirium
- tremens
- death
What alternative treatment is sometimes used in acute alcohol withdrawal when benzodiazepines are contraindicated or not tolerated?
Carbamazepine [unlicensed]
What medications are effective for relapse prevention in alcohol dependence? (2)
Acamprosate and naltrexone (if unsuitable use disulfiram)
Nalmefene= for reducing alcohol consumption in patients with alcohol dependence who have a high drinking risk.
What treatments are effective aids to smoking cessation in nicotine dependence? (3)
Nicotine replacement therapy
bupropion
varenicline
Is nicotine replacement therapy with varenicline or bupropion recommended?
No
How does smoking affect the metabolism of certain drugs, and what adjustment may be needed when smoking is discontinued? (3)
Smoking stimulates the hepatic enzyme CYP1A2
increases the metabolism of drugs such as theophylline, ropinirole, and some antipsychotics
When smoking is discontinued, the dose of these drugs may need to be reduced.
What advice does the MHRA/CHM provide regarding varenicline and suicidal behavior?
Patients should discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood, or suicidal thoughts while taking varenicline.
Patients with a history of psychiatric illness should be monitored closely
How does the withdrawal from methadone or buprenorphine differ from that of heroin?
Methadone or buprenorphine withdrawal occurs later
and has longer-lasting symptoms compared to heroin withdrawal.
What is the recommended course of action for patients who miss 3 days or more of their regular prescribed dose of opioid maintenance therapy?
Patients who miss 3 days or more of their regular prescribed dose of opioid maintenance therapy are at risk of overdose due to loss of tolerance.
Consider reducing the dose in these patients.
What is the difference between buprenorphine and methadone in terms of their pharmacological properties?
Buprenorphine is an opioid-receptor partial agonist, preferred by some patients because it is less sedating than methadone
Methadone, a long-acting opioid agonist, is usually administered in a single daily dose
Why should acute withdrawal of opioids be avoided during pregnancy?
As can cause fetal death.
Is it recommended to continue treatment of opioid dependence during pregnancy?
Yes, treatment of opioid dependence should be continued during pregnancy.
(However, it’s important to note that buprenorphine is not licensed for use in pregnancy)
When should withdrawal of methadone or buprenorphine be undertaken during pregnancy, and why?
Withdrawalof methadone or buprenorphine should only be undertaken gradually during the second trimester.
During the first trimester, there is an increased risk of spontaneous miscarriage, and during the third trimester, maternal withdrawal is associated withfetal distress, stillbirth, and the risk of neonatal mortality
What precautions should be taken regarding the dose of methadone in breastfeeding mothers?
The dose of methadone should be kept as low as possible in breastfeeding mothers.
Neonates and infants should be monitored for drowsiness, adequate weight gain, and developmental milestones.
Adverse effects in breastfed babies should be reported urgently.
What are the indications for Methadone Linctus, and what is its strength?
Methadone Linctus is licensed for analgesia in severe pain and cough in terminal disease.
Its strength is 2mg/5mL.
Which patients should be carefully monitored for QT-interval prolongation while taking methadone? (3)
Patients with risk factors for QT-interval prolongation: heart or liver disease, electrolyte abnormalities,
Patients taking other drugs that can prolong QT interval
Patients requiring more than 100 mg methadone daily
What precautions should be taken regarding methadone overdose?
Methadone overdose requires prolonged monitoring
due to the long-acting nature of the opioid.
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What are some signs of neonatal withdrawal from opioids, and when do they typically develop after delivery? (3)
Signs of neonatal withdrawal from opioids usually develop 24-72 hours after delivery
but symptoms may be delayed for 2 weeks.
Some signs include high-pitched cry, rapid breathing, and hungry but ineffective suckling.
How should doses be managed when breastfeeding while on opioid substitution therapy?
Doses should be kept as low as possible when breastfeeding.
How may drug metabolism change during the 3rd trimester, and how should the dose of methadone be adjusted accordingly? (2)
Drug metabolism may be increased during the 3rd trimester
hence the dose of methadone may need to be increased or changed to twice-daily consumption to prevent withdrawal symptoms.
What is the recommended action if a patient taking a benzodiazepine as part of a withdrawal regimen develops alcohol withdrawal seizures?
a fast-acting benzodiazepine
such as IV Lorazepam or Rectal Diazepam should be given.
After administering a fast-acting benzodiazepine for alcohol withdrawal seizures, what should be considered to prevent further seizures?
an increase in the dose of oral benzodiazepine should be considered to prevent further seizures.
How is Acamprosate calcium used in the treatment of alcohol dependence?
It should be initiated as soon as possible after abstinence has been achieved and continued for 1 year.
Treatment should be maintained if the patient has a temporary relapse but stopped if there is regular/excessive drinking.
When should Naltrexone be stopped in the treatment of alcohol dependence?
Naltrexone should be stopped if drinking continues 4-6 weeks after starting treatment.
What is Nalmefene licensed for in the treatment of alcohol dependence?
licensed for the reduction of alcohol consumption in patients with alcohol dependence
without physical withdrawal symptoms
and who do not require immediate detoxification.
It is* not recommended *for patients aiming to achieve immediate abstinence.
Why should be prescribed for suspected Wernicke’s encephalopathy in alcohol-dependent patients?
Parenteral Thiamine
parenteral thiam can also be given4 prophylaxis in alcohol-dependent pts
Patients with alcohol dependence are at risk of developing Wernicke’s encephalopathy, especially those who are malnourished or have liver disease.
What should be administered following parenteral treatment for Wernicke’s encephalopathy, and for how long?
Following parenteral treatment,
high-dose oral thiamine should be given
until cognitive function is maximized.
How are nicotine patches typically used, and when might a 24-hour patch be suitable?
Nicotine patches are applied for 16 hours (with patch removed overnight) or for 24 hours.
(If patients experience strong cravings for cigarettes on waking, a 24-hour patch may be suitable)
When are immediate release preparations (gum, lozenges, sublingual tablets, inhalator, nasal spray, and oral spray) used in nicotine replacement therapy?
Immediate release preparations are used whenever the urge to smoke occurs or to prevent cravings.
What is a potential side effect associated with oral preparations and inhalation cartridges used in nicotine replacement therapy?
can cause irritation of the throat.
What side effect is commonly associated with gum, lozenges, and oral sprays used in nicotine replacement therapy?
can cause increased salivation
What is a potential side effect of using patches in nicotine replacement therapy?
can cause minor skin irritation
What side effects are commonly experienced with nasal spray in nicotine replacement therapy? (3)
nasal irritation
sneezing
watery eyes
What side effect is associated with oral spray in nicotine replacement therapy? (2)
taste disturbance
flatulence
Which nicotine replacement therapies can cause chest pain? (3)
patches
lozenges
oral spray
What are some common gastrointestinal disturbances associated with nicotine replacement therapy? (4)
nausea
hiccups
dyspepsia
vomiting
may be caused by swallowed nicotine
How does Buprenorphine compare to Methadone in terms of sedation and suitability for tasks like driving?
Buprenorphine is less sedating than Methadone
making it more suitable for patients undergoing skilled tasks like driving.
What advantage does Buprenorphine have over Methadone regarding drug interactions and safety with other sedating drugs? (2)
Buprenorphine is safer than Methadone when used with other sedating drugs
and has fewer drug interactions.
Why may dose reductions be easier with Buprenorphine compared to Methadone?
Dose reductions may be** easier with Buprenorphine**
because** withdrawal symptoms are milder**.
What are some advantages of Buprenorphine regarding overdose risk and dosing frequency? (3)
Buprenorphine has a lower risk of overdose
can be given on alternate days in higher doses
and requires a shorter drug-free period before induction with naltrexone for prevention of relapse.
What adjunctive therapy may be required if symptoms of precipitated withdrawal are severe with Buprenorphine?
Non-opioid adjunctive therapy
such as Lofexidine Hydrochloride
What is levedopa? (4)
Levodopa is a precursor to Dopamine.
It is given with a dopamine-decarboxylase inhibitor (DDI)
to reduce peripheral conversion of levodopa to dopamine
thereby limiting side effects e.g. nausea, vomiting.
What are examples of dopamine receptor agonists? (3)
pramipexole
ropinirole
rotigotine
have direct effect on dopamine receptor agonists
How are **dopamine receptor agonists **typically used in advanced Parkinson’s disease treatment in conjunction with levodopa? (2)
in advanced disease
but at this point, the dose of levodopa is often reduced.
What impulse control disorders are linked with treatment using dopamine receptor agonists and levodopa? (3)
gambling
binge eating
hypersexuality
What action should be taken if impulse control disorders develop during treatment with dopamine receptor agonists and levodopa? (2)
lower dose of drug
or withdraw drug until the symptoms resolve
What caution should be exercised regarding sleepiness when using dopamine receptor agonists and levodopa?
Dopamine receptor agonists and levodopa** can cause excessive sleepiness** and** sudden onset of sleep. **
Caution should be exercised with driving
and driving should be avoided completely if these symptoms are present.
What important safety information should be considered for bromocriptine, cabergoline, and pergolide regarding fibrotic reactions? (3)
These drugs are associated with fibrotic reactions, particularly cardiac valvopathy.
Patients should undergo echocardiography before treatment,
and they should be monitored for symptoms such as dyspnea, persistent cough, chest pain, cardiac failure, abdominal pain, or tenderness.
What are the two drugs used in combination with levodopa to enhance its effectiveness, particularly in treating Parkinson’s disease? (2)
The drugs used with levodopa are:
benserazide (in Co-Beneldopa)
carbidopa (in Co-Careldopa).
How are nausea and vomiting typically managed when using levodopa in combination with benserazide or carbidopa?
Nausea and vomiting with these drugs are rarely dose-limiting
and** domperidone** can be useful in controlling these symptoms.
How should levodopa therapy be initiated to minimize adverse effects? (2)
at a low dose
and increased in small steps.
What medication can be used in advanced Parkinson’s disease for patients experiencing unpredictable ‘off periods’ with levodopa treatment?
Apomorphine
(a dopamine receptor agonist)
How is apomorphine typically administered to patients for self-management of ‘off’ episodes? (3)
Patients must be taught to self-administer apomorphine
by subcutaneous injection into the lower abdomen or outer thigh
at the first sign of an ‘off’ episode.
What is the mechanism of action of entacapone? (3)
Entacapone is a catechol-o-methyltransferase inhibitor
which prevents the peripheral breakdown of levodopa
allowing more levodopa to reach the brain.
In what situation is entacapone particularly useful for patients already on levodopa therapy?
Entacapone is useful in patients on levodopa
who experience ‘end-of-dose’ deterioration.
What is a common side effect of entacapone therapy that patients should be aware of?
can color the urine a reddish-brown color.
What is the mechanism of action of phenothiazines such as Prochlorperazine in treating nausea and vomiting? (3)
act as dopamine antagonists
by blocking dopamine receptors in the chemoreceptor trigger zone (CTZ)
thereby reducing nausea and vomiting.
In which medical conditions are phenothiazines commonly used for treating nausea and vomiting? (4)
commonly used for nausea and vomiting associated with:
* cancer
* chemotherapy
* radiotherapy
* opiods
What is a unique administration route for Prochlorperazine? (2)
as a buccal tablet
which is placed between the upper lip and the gum for rapid absorption.
How does Domperidone differ from Metoclopramide and phenothiazines in terms of side effects?
Domperidone causes less sedation and dystonic reactions compared to Metoclopramide and phenothiazines
because it does not readily cross the blood-brain barrier (BBB).
A combination of two or more antiemetic drugs with different mechanisms of action
such as 5HT3-receptor antagonists, Droperidol, Dexamethasone, Phenothiazines, and Antihistamines
is often indicated for patients at high risk of postoperative nausea and vomiting.
What is the most effective drug for preventing motion sickness?
Hyoscine Hydrobromide
What alternative is available if a sedative effect is desired for motion sickness treatment? (2)
Promethazine
but slightly less sedating antihistamines such as Cyclizine or Cinnarizine are preferred.
Why should we monitor height and weight in children on lisdexemfetamine/ dexamfetamine?
as growth restriction may occur during prolonged therapy
What is the timeframe for the onset of withdrawal symptoms in untreated heroin dependence?
shows early withdrawal symptoms within 8 hours
with symptoms subsiding substantially after 5 days.
