Nervous System Flashcards
What are the 4 most common types of dementia and how do they differ in symptoms?
Alzheimers; memory, repeated questions
Parkinsons
Lewy body; more sleep disturbance and repeated falls/faints
Vascular: CVD and movement problems
What (with what symptoms) calls for pharmacological treatment in dementia?
Cognitive symptoms (memory, concentration, problem solving), severe disease.
Non cognitive only when severely distressed or a danger
What is the drug of choice in mild to moderate dementia due to alzheimer’s with cognitive symptoms?
Anticholinesterase inhibitor
What is the drug of choice in Parkinsons dementia and what is the issue with this treatment?
Rivastigmine. May worsen tremor.
What is the drug of choice in alzheimer’s with severe non cognitive symptoms?
Antipsychotic or benzodiazapines
What is the drug of choice in severe alzheimer’s wihh cognitive symptoms?
Memantine
What is the issue with antipsychotic use in dementia patients
Increased risk of stroke and death in elderly dementia. Balance risk factors.
In what conditions would acetylcholinesterase inhibitors be cautioned or avoided?
Caution in asthma and COPD as may exacerbate, peptic ulcers, use with NSAIDs/steroids/rate limiting drugs. Avoid in heart block and sick sinus syndrome
When should the efficacy of treatment be assessed in dementia?
At 3 months.
What are the most common side effects of acetylcholinesterase inhibitors?
Nausea, vomiting and diarrhoea
What dose considerations should be given for anti epileptic in children?
Interval may need to be reduced as metabolised quicker
What are the category 1 anti epileptics for maintaining brand?
Phenytoin, carbemazepine, phenobarbital and primidone
Which antiepileptics have the highest risk of antiepileptic hypersensitivity syndrome?
Carbemazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide
What are the main symptoms of antiepileptic hypersensitivity syndrome?
Fever rash lymphadenopathy
Upon withdrawal of an antiepileptic, how long before someone can normally drive?
6 months after last dose
Besides valproate, what other antiepileptic drugs have risk of teratogenicity?
Phenytoin, primidone, phenobarbital, lamotrigine, carbemazepine, topiramate
Which antiepileptics may need their doses changing during pregnancy?
Phenytoin, carbemazepine, lamotrigine
Which antiepileptics should be cautioned for use during breastfeeding and why
Primidone, phenobarbital, benzodiazepines. Established risk of drowsiness
Besides hypersensitivity, what other symptoms should patients look out for with carbemazepine?
Bruising, bleeding, mouth ulcers (blood disorders)
Reduced appetite, abdominal pain (liver toxicity)
Which antiepileptics are best tolerated?
Levetiracetam, Pregablin and gabapentin
Which antiepileptic is used in children but can cause serious rashes?
Lamotrigine
What should be monitored during dos phenytoin infusion?
Heart rate, blood pressure and respiratory function
What is the normal plasma concentration for phenytoin and when might it change?
10-20mg/L. Protein binding my be reduced in pregnancy, elderly, diseased and in first 3 months of life
At what age do symotoms normally appear for ADHD?
3 - 7
What is the first line drug treatment for ADHD and how long is it trialed for before trying others?
Methylphenidate for at least 6 weeks. Or atomoxetine if risk of abuse.
What effects should patients look out for with treatment for atomoxetine?
Agitation, suicidal thoughts, potential for liver damage (unexplained nausea, malaise, darkened urine, jaundice)
What should be recorded 6 monthly during ADHD treatment?
Pulse, BP, psychiatric symptoms, appetite, weight and height
How long should treatment persist for mania?
At least 2 years from last manic episode or 5 years if risk of relapse
What adjunctive drugs may be given in mania and when should they be avoided
Antidepressants - avoid with rapid fluctuation or hypomania
Benzodiazepine but only short term
What drug therapy is recommended in acute hypomania and mania?
Atypical antipsychotic. Add lithium or valproate if uncontrolled
What drug is useful in rapid cycling mania?
Carbemazepine
What is the target lithium levels?
0.4-1mmol/l
0.8-1 if manic episode
Samples should be taken 12h after dose.
What should be monitored in lithium patients and how often?
Body weight, electrolytes, EGFR, thyroid function. 6 monthly.
What are the symptoms of liver toxicity and what else should patients look out for with lithium treatment?
Vomiting, diarrhoea, muscle weakness, confusion, drowsiness, hypernatreamia.
Hypothyroidism, headache, visual disturbance
Patients with non cognitive symptoms in dementia should be prescribed antipsychotic drugs. True or false
Only if Severe due to increased risk of stroke and death
What side effects can anticholinesterases have?
Blurred vision, urinary incontinence
Which antiepileptics can be given once daily?
Lamotrigine, parampenel, phenobarbital and phenytoin
What monitoring should occur with fosphenytoin?
HR, BP, respiratory function during infusion and observe at least 3o minutes after
Vitamin D supplements should be considered with which antiepileptics?
Phenytoin, phenobarbital, sodium valproate, primidone
What are the symptoms of phenytoin toxicity?
Nystagmus, diplopia, slurred speech, ataxia, confusion, hyperglycemia
What symptoms to look our for and monitoring should be done with valproate?
Raised liver enzymes
Abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness
Pancreatitis
Pregnancy prevention programme
How long should valproate be reduced over?
4 weeks
What issues have topiramate been associated with?
Acute myopia with secondary angle closure glaucoma within 1 month of starting. Raised intra ocular pressure
Congeniral abnormalities
What issues has vigabatrin been associated with?
Visual field defects from 1 month to several years after starting. Test 6 monthly and report visual disturbance
Whta should infants be monitored for during breastfeeding in benzodiazepine use?
Sedation, feeding difficulties adequate weight gain and development milestones
For what medicines is the risk of impaired skilled tasks period extended and for how long?
24 hours with short general anaesthetics and IV benzodiazepines
What benzodiazepines are safer in hepatic impairment?
Those with shorter half lives. Temazepam, oxazepam
Can taking benzodiazepines effect your behaviour?
Yes paradoxical effects in hostility and aggression may be reported. Talkative Ness and excitement to aggression and antisocial behaviour. Anxiety. Perceptual disorder.
An overweight patient is prescribed a benzodiazepine, which may be effected by his weight?
Midazolam accumulates in adipose tissue
Are benzodiazepines safe in pregnancy?
Risk of neonatal withdrawal symptoms. Avoid regular use and only when clear indication. High doses in late pregnancy may cause neonatal hypothermia, hypotonia and respiratory depression
What should be monitored for with lis/dexamfetamine?
Growth in children. Discontinue if tics occur. (just dex)
Pulse, BP, appetite, weight and height every 6 months. Aggressive behaviour and hostility in initial treatment in both
Can amfetamines be mixed with food?
Lis dexamfetamine can be mixed with soft food or in water/orange juice.
What should be monitored with guanfacine?
Baseline evaluation of somnolence, sedation hypotension bradycardia, qt prolongation and arrhythmia. Monitor for side effects and bmi (3m in first year then 6m)
How should antipsychotics be discontinued?
Over at least 4 weeks if continuing with other antimanic drugs or up to 3 months if not
How long does the prophylactic effect of lithium take to occur?
6-12 months
What signs should be monitored in valproate treatment?
Raised liver enzymes and prothrombin time may be transient but could be linked to liver dysfunction
A patient prescribed lithium will be on it lifelong. True or false.
False. Continued therapy should be assessed regularly due to risk of Thyroid disorder (monitor 6m) and memory impairment. Patients maintained on lithium past 3 - 5 y only if benefit persists.
What are the signs of lithium toxicity?
Diarrhoea, vomiting visual disturbance, polyuria, muscle weakness, fine tremor to coarse tremor, cns disturbance (confusion, drowsiness), Myoclonus, incontinence, hypernatremia. Arrhythmia, seizures, renal failure if Severe.
Which class of antidepressants are first line?
SSRIs. Less antimuscarinic and cardio toxic effects than tricyclics and maois have food interactions
What time frames are given to antidepressant therapy for reviews, remission and effect?
Review every 1 to 2 weeks at start. Continue for at least 4 weeks. 6 in elderly before considering a switch. Continue following remission for further 6 months (12m in elderly or Gad). Maintenance for at least 2 years if recurrent.
Maois may take longer to work (3 weeks or more and additional 1-2 for maximal).
Which antidepressants cause Hyponatreamia?
All. But more with SSRIs
Why does there need to be a break between certain antidepressants during a switch? Which?
Longer half lives may I crease risk of serotonin syndrome
Other antidepressants (incl MAOI) should not be stated for 2 weeks after MAOI stopped (3 weeks if starting imipramine or clomipramine). Maois should not be started until 7-14 days after tricyclic (3 weeks after above 2) has stopped, or until a week after ssri (5 weeks if fluoxetine) stopped
Which tricyclics are more sedative?
Amitriptyline, clomipramine, dosulepin, doxepin, Mianserin, trazadone and trimipramine
Lofepramine has less cardio toxic side effects but what else can it cause?
Hepatic toxicity
Which depressed patients respond best to Maois?
Phobic or with atypical, hypochondriac or hysterical features.
When can vortioxetine or tryptophan be used?
Vortioxetine if non responsive to 2 antidepressants within current episode
Tryptophan by hospital specialists
What should patients on MAOIs avoid?
Food suspected of stale or going off especially meat fish poultry or offal. Avoid game. Persists 2 weeks after stopping. Avoid alcoholic or dealcoholised drinks. Tyramine rich food (mature cheese, yeast, fermented soya bean)
What advice is given by the royal college of psychiatrists on doses of antipsychotic drugs?
Before increasing above bnf upper limit consider alternative approaches such as adjuvant or newer drugs such as clozapine,
Bear in mind risk factors including obesity and particular caution in elderly over 70
Consider drug interactions
Carry out ECG to exclude prolonged qt
Increase dose slowly and no more often than weekly
Carry out regular pulse, blood pressure, and temperature checks and ensure adequate fluid intake
Consider high dose for limited period and review regularly. Abandon if 3 months with no improvement
What are positive and negative symptoms of schizophrenia?
Positive is thought disorder, hallucinations delusions
Negative is apathy social withdrawal
How are first generation antipsychotic drugs grouped for side effects?
Group 1 (chlorpromazine, levomepromazine and promazine) prounounced sedative and moderate antimuscarinic/extrapyrimidal
Group 2 (pericyazine) moderate sedative, fewer extrapyrimidal
Group 3 (fluphenazine, perphenazine, prochlorperazine, trifluoperazine) fewer sedative and antimuscarinic but more pronounced extrapyrimidal. Same with butyrophenones (haloperidol benperidol)
Thioxanthenes (flupentixol, zuclopenthixol) moderate of all
Pimozide and sulpride reduced of all
EPS also common with depot
What are the extrapyrimidal side effects?
Parkinsonism (tremor) , dystonia (abnormal face and body movements), akathisia (restlessness), tardive dyskinesia (rhythmic involuntary, most serious as may be irreversible)
What effect do antipsychotics have on prolactin? Which?
Increase (as dopamine inhibits). Except aripiprazole which reduces as partial agonist. Rispeidone, amisulpride and first gen more likely. Sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement and galactorrhoea.
Which antipsychotics most commonly cause sexual dysfunction and why?
Reduced dopamine transmission and hyperprolactinaemia decrease libido. Rispeidone and haloperidol
Which antipsychotics are at most rijs of diabetes?
Clozapine, olanzaoine, quetiapine and rispeidone
A patient taking an antipsychotic is experiencing hyperthermia, muscle rigidity, tachycardia and urinary incontinence. What may they be experiencing and what should be done.?
Neuroleptic malignant syndrome. Discontinue antipsychotic
Which type of antipsychotics works best on negative symptoms?
Second gen
What monitoring is done with antipsychotic?
FBC, U&Es, LFTs at start and annual.
Lipids and weight at baseline, 3m then yearly
Fasting blood glucose at baseline 4-6m, then yearly.
Why are FBCs particularly important with clozapine?
Neutropenia and potentially fatal agranulocytosis reported. Must be normal before starting. Monitor every week for 18 weeks then at least every 2 weeks. 4 weeks after stable for a year. 4 weeks after discontinuation.
Does constipation with clozapine warrant discontinuation?
It should be recognised and actively treated due to impairment of intestinal peristalsis leading to intestinal obstructions.
What can be used for muscular symptoms in movement disorder eg motor neurone disease?
Quinine first line. Then baclofen. Tizanidine, gabapentin and dantrolene considered.
What is used to treat saliva problems in motor neurone disease or Parkinsons?
Antimuscarinics. Glycopyrronium if cognitive impairment. Botulinum with referral (second line in Parkinsons) Humidification, nebulisers, carbocisteine
Why might opioids or benzodiazepines be used in motor neurone disease?
For breathlessness exacerbated by anxiety
What area of the brain is effected in Parkinsons?
Substantia nigria
What must be done once a patients Parkinsons diagnosis is confirmed?
Inform dvla and car insurer
Which drug is most suitable if Parkinsons patients have their quality of life effected by motor symptoms?
Levodopa but motor complications more likely
What are the main adverse effects associated with antiparkinsons
Psychotic symotoms
Excessive sleepiness and sudden onset of sleep (dopamine receptor agonists)
Impulse control disorders (especially dopamine receptor agonists) particularly if previous impulse behaviour alcohol consumption or smoking
Which drug is immediately not considered for Adjunct therapy with levodopa if motor fluctuations occur?
Ergot derived dopamine receptor agonists (only if not adequately controlled with non ergot)
What can be given for daytime sleepiness in Parkinsons?
Modafinil if pharmacological causes excluded.
What can be used for postural hypotension in Parkinsons?
Midodrine first line. Fludrocortisone as alternative
Are antipsychotics used in Parkinsons?
Quetiapine or clozapine can be to treat hallucinations and delusions. Phenothiazines and butyrophenones can worsen motor features.
What can be given for rapid eye movement in Parkinsons?
Clonazepam or melatonin
What is given in advanced Parkinsons disease?
Apomorphine. Domperidone for nausea and vomiting associated (admin 2 days before) but assess cardiac risk factors.
Levodopa/carbidopa intestinal gel if Severe motor fluctuations and hyperkinesia or dyskinesia.
deep brain stimulation
Which antiparkinsons medication needs extra counselling to prevent worry to patients?
Entacapone colours urine reddish brown
What is a major caution of tolcapone?
Hepatitoxicity. Usually in women during first 6 months. Test before and every 2 weeks in first year, then every 4 weeks for 6m then every 8 weeks. Tell patients to seek attention with anorexia nausea, vomiting fatigue, abdominal pain, dark urine or Pruritis.
Why should antiparkinsons medication never be abruptly withdrawn?
Small risk of neuroleptic malignant syndrome
What monitoring is required with apomorphine?
Hepatic, haemopoeitic renal and cardio function
Test initial and 6m anaemia and thrombocytopenia if used with levodopa
Can dopamine receptor agonists be used in pregnancy?
Most avoid.
Bromocriptine should not be used postpartum or in puerperium if high BP, CAD, mental disorder. Provide contraceptive advice if appropriate.
Cabegoline exclude pregnancy and discontinue 1 month before intended and if pregnancy occurs.
What different types of drugs can be used in nausea/vomiting and when are they preferred?
Antihistamines - pregnancy vomiting
Phenothiazines - neoplastic disease, radiation, drug induced (chlorpromazine most sedative). Can be rectal or buccal if vomiting severe.
Other antipsychotics in terminal illness (haloperidol, levomepromazine)
Metoclopramide - gastro, hepatic, biliary
Domperidone - less likely for BBB side effects
Serotonin receptor antagonists - chemotherapy
Dexamethasone - chemotherapy
NK1 receptor antagonists - chemotherapy
Nabilone (cannabinoid) - chemotherapy
What options of antiemtics are there in pregnancy?
Antihistamine eg promethazine
Prochlorperazine or metoclopramide
Hyperemesis gravidarum - regular therapy, fluid and electrolytes. Maybe nutrition or thiamine if risk of wernicks
What risk factors are there for post op nausea and vomiting?
Female, non smokers, history and opioid use.
What is the most effective drug for motion sickness prevention?
Hyoscine hydro bromide. Sedating antihistamines are better tolerated (cyclizine/cinnarizine preffered over more sedating promethazine)
What antiemetic can reduce effectiveness of hormonal contraception?
NK receptor antagonists
What pain are paracetamol, NSAIDs and opioids each suitable for?
Paracetamol and NSAIDs for musculoskeletal
Opioid for moderate to severe, particularly visceral
What drugs should be given in dental pain?
NSAIDs most suitable as anti infnflammatory. Opioids relatively ineffective. Benzydamine if acute pain of oral mucosa
Which analgesics are less suitable post operatively?
Tramadol not as effective as others for severe pain. Buprenorohine may antagonise previously administered opioids. Pethidine has toxic metabolite.
Why are fentanyl patches unsuitable for a patients first opioid?
Not suitable for acute pain or changing analgesic requirements as time to steady state is long and cannot be titrated. Only in opioid tolerant.
What is the maximum daily dose of codeine in under 18 year olds?
Not to be used under 12. Max 240mg if older.
What is the issue of ultra rapid metabolisers of codeine?
Morphine toxicity may occur.
What are the serious side effects of opioids?
Respiratory depression, including in neonates if used during delivery. Dependance, tolerance, withdrawal. Overdose (coma, respiratory depression and pinpoint pupils)
What drugs are associated with medication overuse headache?
Opioid and non opioid analgesics, 5ht1 receptor agonists, ergotamine
Why are dispersible preparations more suitable for migraine?
Peristalsis reduced during attacks so quick absorption needed
Which antiemetics promote peristalsis?
Metoclopramide, Domperidone
What classes of drug may be used to prevent migraine?
Beta blockers, tricyclic antidepressants, antiepileptics.
Cluster headaches should only be treated with standard analgesics. True or false.
False, they are rarely responsive. Sumatriptan by SC injection, oxygen.
Verapamil or lithium for prophylaxis
What are the treatment issues with paramax and migramax?
Contain metoclopramide. Can cause severe extrapyrimidal side effects especially in children and young people so don’t exceed 3 months
What symptoms warrant discontinuation of triptans?
Heat, heaviness, pressure or tightness (throat or chest)
How should triptans be administered?
One dose as soon as possible after onset, then another dose after 2 hours if recurs (not if no response at all)
Rizatriptan 10mg
Propranolol 40mg
What is the issue?
Max 5mg with propranolol
What opioid analgesics can be used in neuropathic pain?
Efficacy evidence for tramadol, morphine and oxycodone
What may decrease adherence to capsaicin cream?
Intense burning in initial treatment
What are the treatment options for Trigeminal neuralgia?
Surgery. Carbemazepine. Phenytoin sometimes.
Which drugs are and aren’t recommended as anxiolytics and hypnotics?
Benzodiazepines are most common.
Meprobamate and barbiturates are not recommended due to side effects, interactions and danger in overdose.
How should benzodiazepines be withdrawn?
Transfer stepwise to equivalent diazepam dose
Reduce this dose by 1-2mg every 2 - 4 weeks or by one tenth if high doses. Maintain if uncomfortable until symptoms lessen.
Steps of 500mcg may be necessary towards end.
What are withdrawal symptoms of benzodiazepines and how long may it take to experience and resolve?
3 weeks after stopping (with long acting) or within a day (with short acting). Confusion, toxic psychosis, convulsions, delerium tremens if abrupt. Insomnia, anxiety loss of appetite/weight, tremor, tinnitus.
Usually resolves within 6 - 18 months after last dose but may be longer/shorter depends on person.
Which benzodiazepines are long and short acting?
Nitrazepam, flurazepam, diazepam, alprazolam, chlordiazepoxide, clobazam (prolonged)
Loprazolam, lormetazepam, temazepam, lorazepam, oxazepam (shorter)
Which hypnotic is most useful in elderly?
Chlormethiazole
Is alcohol considered a hypnotic?
No. It has diuretic action interfering with sleep and disturbs sleep patterns.
Can buspirone and benzodiazepines be used together?
Advisable to withdraw benzodiazepines before starting buspirone
Varenicline or bipropion may be used with NRT. True or false.
No, not recommended together
Why does smoking effect the dose of some drugs? Which?
It stimulates CYP1A2. Particularly theophylline, cinacalcet, ropinorole, antipsychotics.
When are each of the NRT formulations preferred?
Patches - 24h for cravings on morning
What side effects can occur with NRT?
Local irritation. Oral irritation. Increased salivation. Coughing, nasal irritation, sneezing, watery eyes. Blurred vision. Gastro intestinal disturbance if swallowed eg nausea, vomiting, dyspepsia, Hiccup. Dry mouth.
Palpitations, arrhythmia, chest pain. Atrial fibrillation
Abnormal dreams (remove patcg before bed) , paraesthesia.
Rash, hot flushes
What are the advantages and disadvantages of buprenorohine over methadone?
Less sedating, fewer interactions, milder withdrawal, lower overdose risk.
Increased risk of precipitated withdrawal when other opioid agonists in circulation. Give 6-12 hours after other short acting opioid or 24-48 hours after methadone.
Opioid substitution is better in pregnancy rather than withdrawing cold turkey from illicit drugs. True or false.
True. Don’t withdraw at all in first trimester (miscarriage) . Withdrawal regime can start during second. Also not recommended in third (stillbirth, distress) and drug metabolism may increase so may need BD.
What are the signs of neonatal withdrawal from opioids?
High pitched cry, rapid breathing, hungry but ineffective suckling, excessive wakefulness usually within 24-72h but may be delayed up to 14 days.
How does naltrexone prevent relapse?
Precipitates withdrawal symptoms and blocks effects of opioid receptor agonists
What is given if alcohol withdrawal seizures occur and why?
Lorazepam. Fast acting benzodiazepine
What vitamins may be needed for alcohol dependant patients?
Thiamine due to risk of wernicks
When are corticosteroids given in alcohol dependance?
Hepatitis with discriminant function of 32 or more. Short term 1 month.
What advice should be given with disulfiram ?
Reactions may occur following exposure to alcohol including in perfume, sprays and non alcohol beers/wines. Nausea, flushing, palpitations.
Seek medical attention if unwell with symptoms such as fever or jaundice (Hepatitoxicity)
