Nervous System Flashcards
(108 cards)
1
Q
How are cognitive symptoms (memory impairment, confusion) in dementia caused by Alzheimer’s disease managed?
Give the classes of drugs and examples.
A
Acetylcholinesterase inhibitors- donepezil, galantamine, rivastigmine.
MDMA receptor antagonist - memantine- max 20mg OD (note this is first line in severe Alzheimers)
2
Q
How are non-cognitive symptoms (delusions, anxiety, aggression) managed?
A
Antipsychotics
Acetylcholinesterase inhibitors or memantine
3
Q
What is a specific MHRA advice in elderly patients with dementia?
A
Increased risk of stroke, TIA and death when antipsychotics are used in elderly patients with dementia.
4
Q
What is a specific side effect of galantamine?
A
Serious skin reactions including Stevens - Johnsons syndrome. STOP if rash occurs.
5
Q
Which anti-epileptics are Category 1 meaning patients should be maintained on a specific brand?
A
CPPP
carbamazepine
phenytoin
phenobarbital
primidone
6
Q
Which anti-epileptics are Category 2 meaning patients may be need to be maintained on a specific brand?
A
valproate, lamotrigine, clobazam clonazepam, topiramate, oxcarbazepine,
7
Q
Which anti-epileptics do not need to be prescribed by brand?
A
levetiracetam, gabapentin, pregabalin, ethosuximide.
8
Q
Which drugs lower seizure threshold?
A
tramadol quinolone- e.g ciprofloxacin carbapenems SSRIs TCAs clozapine
9
Q
What is antiepileptic hypersensitivity syndrome and which anti-epileptics can cause it?
A
Rare but fatal reaction to an antiepileptic- rash, fever, organ failure.
Can be caused by: CPPP (carbamazepine, phenytoin, phenobarbital, primidone) lacosamine, lamotrigine, oxcarbazepine
10
Q
How long must you wait to drive after a single isolated seizure (or after a dose change) ?
A
6 months
5 years if bus/ lorry driver
11
Q
How long must you wait to drive after a diagnosis of established epilepsy?
A
1 year seizure free
10 years if bus/lorry driver
12
Q
How long must you wait to drive if you get sleep seizures?
A
1 year seizure free
1 year if seizures only ever occur at night
3 years if seizures now occur at night only but have previously had awake seizures.
13
Q
What should a woman who is taking anti-epileptic medication do if she becomes pregnant?
A
Do not stop taking meds as seizure harmful to foetus- see specialist.
Reassure them there is still 90% chance of a child with no malformations.
They should notify the UK epilepsy and pregnancy register.
Routine vitamin K injections at birth reduce risk of neonatal bleeding.
14
Q
Which antiepileptics most readily transfer into breastmilk?
A
ZELP
zonasimide
ethosuximide
lamotrigine
primidone
15
Q
Which anti-epileptics cause established drowsiness to a breast-fed infant and are also most likely to accumulate and cause withdrawal in the infant?
A
LPP
lamotrigine
phenobarbital
primidone
benzodiazepines.
16
Q
What anti-epileptic is first line for all seizure types except focal where its second line?
What is first line in focal seizures?
What is a common second line option for most seizures?
A
Sodium valproate
First line for focal seizures- Carbamazepine/ lamotrigine.
Lamotrigine. Carbamazepine (if focal/tonic clonic)
17
Q
In what type of seizures are CPPGTV (carbamazepine, phenytoin, pregabalin, gabapentin, tiagabine, vigabatrin) not recommended?
A
Absence, myoclonic, atonic and tonic seizures.
They can only be used for focal and tonic- clonic.
18
Q
What is important before starting carbamazepine and related anti-epileptics and phenytoin therapy?
A
Screen Hans Chinese or Thai patients for HLA-B1502 allele. If the patient dose have this allele, avoid the drug as these patients are at a higher risk of Stevens- Johnsons syndrome.
19
Q
What are some important side effects of carbamazepine?
What supplementation may patients on this drug need?
A
Blood disorders -requires withdrawal
Hepatic disorders
Skin disorders
Vitamin D if immobile or inadequate sun time or if low dietary calcium.
20
Q
What is the MHRA alert associated with gabapentin?
A
Rare risk of severe respiratory depression
21
Q
What can occur in patients with low body weight (<50kg) receiving high doses of gabapentin liquid (Rosemont)?
A
Levels of propylene glycol and saccharin (excipients in the liquid) that exceed WHO RDI.
22
Q
What drug can increase plasma levels of lamotrigine and requires use of reduced lamotrigine doses?
A
Valproate
23
Q
What is the target plasma concentration of phenytoin?
A
10-20mg/L
24
Q
What are some side effects of phenytoin?
Are there any specific cautions?
A
Rash - STOP drug serious skin reactions blood disorders With IV use: hypotension and bradycardia Vitamin D deficiency- may need supplementation.
Enteral feeding- interrupt feeding 2 hours before and after dose.
25
Whats is a notable side effect of topiramate that requires treatment cessation?
Occular issues- myopia (near-sighted), glaucoma, raised intraoccular pressure.
26
What is a potential side effect of zonasimide?
Overheating and dehydration in children.
AVOID things that will cause overheating such as exercise.
27
Which anti-epileptic is contraindicated in visual field defects?
Vigabatrin
28
What is the MHRA alert regarding sodium valproate?
Contraindicated in women of childbearing age. Only to be used if conditions of PPP (pregnancy prevention programme) are met and ONLY for EPILEPSY when there are no other options
PPP
- Given patient guide, review by specialist with last year, on highly effective contraception.
- Annual review with specialist- complete and sign risk acknowledgement form
- Pharmacists must dispense whole packs where possible, warning label (or sticker) on all containers, discuss risks each time a prescription is collected.
29
How is status epileptics managed?
Seizures > 5minutes
IV lorazepam. can be repeated after 10 minutes
IV diazepam ( VTE risk if given IV- less with emulsion)
Midazolam (buccal) or diazepam rectal solution (NOT - IM/ suppositories absorption too slow!)
If alcohol excesss suspected give pabrinex
Seizures lasting > 25 minutes
(fos) phenytoin or phenobarbital (NOT IM)
Seizures lasting >45 minutes
anaesthesia with thiopental, midazolam, propofol.
Patient will need full ITU support.
30
How are febrile convulsions managed
Paracetamol but if it lasts > 5 mins, treat as status epilepticus.
31
How is ADHD managed?
First line- methylphenidate
Second line- dexamphetamine or atomoxetine
Third line- lisdexamphetamine guanfacine
**Beware: risk of suicidal thoughts with these meds**
32
How long should treatment for bipolar continue?
2 years from last manic episode.
| 5 years if at risk of relapse.
33
How is mania managed? Acutely and long term.
Benzodiazepines in initial stages
Antipsychotics: olanzapine/ quetiapine/risperidone
Long term management: lithium/ valproate/olanzapine.
Carbamazepine is useful in rapid cycling bipolar.
34
What do you know about lithium?
Cover levels, pre/post dose levels, monitoring, side effects, toxicity.
Levels- 0.4-1mmol/L (narrow therapeutic index)
Samples 12 hours post dose
Levels weekly at first then every 3 months
Every 6 months- TFTs, FBC, U+Es, BMI
Withdraw drug over at least 4 weeks- 3 months ideal
Long term use- thyroid disorders, nephropathy, weight gain, abdominal issues.
Toxicity- N+V, diarrhoea, coma, confusion, tremor
35
What do you know about SSRIs?
Include side effects and max doses.
First choice in patients with UA or recent MI is sertraline.
contraindicated in poorly controlled epilepsy
Initiate doses slowly and withdraw slowly (4 weeks)
Side effects- BADSSRI
body weight increase, anxiety, dizziness, sedation, suicidal thoughts, reproductive dysfunction, insomnia, bleeding disorders, cardiac disease (arrhythmias), QT prolongation,
Hyponatraemia- especially in the elderly
Max doses- citalopram 40mg, fluoxetine 60mg, sertraline 200mg OD
36
How long should antidepressants be continued after remission?
6 months
12 months if elderly or if using for generalised anxiety disorder.
2 years if recurrent depression.
37
What is a common side effect of all antidepressants
Suicidal thoughts especially with those with a history of these thoughts and children + young adults.
38
How is anxiety disorder managed?
Acutely: a benzo or buspirone
```
Chronic anxiety (> 4 weeks): antidepressants
GAD : SSSRI, SNRI or pregabalin
```
39
How are panic disorder, OCD, PTSD and social anxiety disorder managed?
SSRI first line for all of them
Clomipramine is second line for panic disorder and OCD
Moclobemide is licensed for social anxiety disorder
40
Which are the sedating and which are the less sedating tricyclic antidepressants?
when would each be preferred?
Sedating- amitriptyline and dosulepin
Preferred in agitated patients
Less sedating- nortriptyline, lofepramine.
Preferred in withdrawn (flat) patients
41
What do you know about TCAs?
Overdose is dangerous- high fatality- cardiotoxicity especially with amitriptyline + dosulepin.
Signs of overdose- mydriasis (dilated pupils, coma etc)
Cause antimuscarinic side effects, arrhythmia, hyponatraemia.
Can cause withdrawal- start and taper gradually
42
What do you know about monoamine oxidase inhibitors?
Include examples, Interactions, side effects
- examples- isocarboxazid, phenelzine, moclobemide.
- Many dangerous food and drug interactions.
- Risk of interaction persists for 2 weeks after stopping.
- Hypertensive crisis can occur if given with tyramine rich foods (fermented foods- cheese, beer, salami) and alcohol.
- They can cause postural hypo/hypertension (tranylcypromine is the worst)
- They cause hepatotoxicity
- Can cause withdrawal- start and taper gradually
43
What should be done when starting/ stopping a MAOI?
Other antidepressants should only be stated after 2 WEEKS (3 weeks if starting clomipramine/ imipramine)
An MAOI should not be started until:
2 WEEKS after a previous MAOI is stopped
1 WEEK after stopping SSRI (5 weeks for fluoxetine)
1-2 WEEKs after TCA (3 weeks if clomip /imipramine)
44
What class of drug are duloxetine and venlafaxine?
SNRIs
45
What are the first generation antipsychotics and what are some of the side effects?
Phenothiazines such as chlorpromazine, levomepromazine (sedating)
Butyrophenones such as haloperidol
Thioxanthenes such as flupentixol
These block D2 and cause a range of side effects such as extrapyramidal symptoms and elevated prolactin.
46
What are the issues surrounding antipsychotics in the elderly.
Risk of mortality, stroke and TIA if patient has demetia
Only use if severe symptoms
Initial doses should be half adult doses and review regularly.
47
What are some examples of second generation antipsychotics?
aripiprazole, clozapine, olanzapine, quetiapine, risperidone, amisulpiride.
48
What are extrapyramidal symptoms that are possible with antipsychotics?
Parkinsonian symptoms (e.g tremor)
dystonia (muscle spasms)
tarditive dyskinesia (stiff jerky movements)
akathisia (restlessness)
These symptoms should stop when the drug is withdrawn. An antimuscarinic can be added to reduce the symptoms.
Mostly caused by 1st generation- less so by 2nd gen.
49
What is hyperprolactinamea?
Which medicines affect this?
High prolactin leading to breast enlargement, sexual dysfunction, menstrual issues.
1st generation antipsychotics, risperidone, amisulpiride cause this most commonly.
50
Which antipsychotic can REDUCE prolactin?
aripiprazole
51
Which antipsychotics most commonly cause sexual dysfunction?
risperidone and haloperidol
| Reduce dose/ switch med
52
What are the key side effects associated with antipsychotic drugs?
Cardiac problems- arrhythmias, hypotension
QT prolongation can occur with pimozine and haloperidol, IV + high dose- can cause sudden death.
Hyperglycaemia + diabetes (2nd generation more likely to cause this)
weight gain- esp. clozapine and olanzapine.
Photo sensitivity with high doses- avoid sunlight
Neuroleptic malignant syndrome.
53
What is neuroleptic malignant syndrome?
Muscle rigidity, tachycardia,etc.
Rare but potentially fatal
STOP drug. no effective treatment but bromocriptine (dopa agonist) and dantrolene (muscle relaxant) can be used.
54
What are the terms surrunding initiation of clozapine?
Only after 2 other antipsychotics (6-8 week trial each) have failed to work.
All patients must sign up to monitoring service
If no response check cloz levels before increasing dose
55
What do you know about clozapine?
- Can cause severe neutropenia and agranulocytosis.
- STOP if leucocyte <3000 or neutrophils <1500.
- Monitor bloods weekly for 18 weeks then fortnightly for 1 year, then monthly thereafter- part of monitoring service
- Can cause fatal myocarditis + cardiomyopathy especially in first 2 months.
56
What is the MHRA alert regarding clozapine?
Potentially fatal risk of intestinal obstruction and faecal impaction. Treat constipation ASAP.
57
What do you know about antipsychotic depot injections?
- All have decanoate in the name
- Deep IM oily injections- max 2-3ml per site.
- Used for maintenance if poor compliance
- More extrapyramidal symptoms
- Usually given every 2-4 weeks
- Give test dose first.
58
Which antipsychotic tablets should not crushed and handled by HCPs due to sensitisation risk?
Chlorpromazine
59
Which antipsychotic does not affect blood pressure as much as the others?
sulpiride
60
How are the muscular symptoms of motor neurone disease managed?
1st line- quinine
2nd line- baclofen
3rd line- tizanidine, dantrolene, gabapentin
61
How is hypersalivation managed in motor nerone disease?
1st line- glycopyrronium (antimuscarinic)
| 2nd line- botox
62
Which drug can be used to extend life in ALS motor neurone disease?
Riluzole
63
Do patients with parkinsons need to inform the DVLA?
yes
64
What is the treatment pathway for the motor symptoms of Parkinson's disease?
-Delay treatment for as long as possible.
1st line: co-careldopa/ co-beneldopa
If symptoms do not affect QOL, can also use as first line: non-ergot dopa agonists (pramipex, ropino, ritigotine) OR MAIO- Bs (rasagaline/ selegiline)
2nd line: co-ben/co-carel + any of above
Can also add/ use one of the following instead:
COMT- inhibitors (entacapone),
Can use ergot-derived dopa agonists (bromocriptine, carbegoline, pergolide) ONLY if non-ergot dont work.
3rd line: + amantadine
65
Why should abrupt withdrawal of parkinsons medicines be avoided?
Risk of neuroleptic malignant syndrome + rhabdomyolysis
66
How can excessive sleepiness (common in patients with parkinsons) be managed?
modafinil
| adjusting drugs if caused by medicines.
67
How can psychotic symptoms such as hallucinations and delusions in parkinsons be managed?
clozapine
Quetiapine (if no cognitive impairment)
NOTE: other antipsychotics WORSEN motor symptoms of parkinsons disease so AVOID.
68
How can postural hypotension (common in parkinsons) be managed?
midodrine
| fludrocortisone
69
What medication can be started in refractory parkinsons?
Are there any precautions surrounding its use?
apomorphine
Causes major N+V so give domperidone 2 days before.
QT prolongation can occur with the combination so check ECG first.
70
Which parkinsons meds may need a reduction in levodopa dose if used concurrently?
COMT inhibitors Entacopone/ tolcapone
MAOI-B - selegiline
Levodopa dose reduction by 10-30%
71
What can COMT inhibitors (eg entacopone) cause?
Hepatotoxicity
72
What is a major side effect associated with parkinsons medicines especially levodopa and the dopa agonists (cabegoline, pramipexole, etc)
impulsive behavious (e.g gambling)- stop/ reduce dose
73
What are the risks with abrupt withdrawal of levodopa?
Risk of rhabdomyolosis + neuroleptic malignant syndrome.
74
By how much should you reduce the dose from MR to dispersible levodopa?
Approximately 30%
75
When transferring patients between levodopa, when should the previous preparation be stopped?
12 hours before
76
What is in stalevo?
Levodopa, carbidopa, entacapone
77
Why are carbidopa and benserazide used with levodopa?
Levodopa is converted to dopamine in the brain
| They stop the breakdown of levodopa before it can reach the brain and take effect.
78
What is a side effect associated with cabergoline?
Fibrotic reactions- pulmonary, cardiac, perinoneal
79
Which parkinsons medicines can also be used to suppress lactation?
bromocriptine, cabergolide pergolide
80
Which parkinsons medicine requires dose titration after one missed dose?
ropiniorole
81
Which antiemetics are INEFFECTIVE for motion sickness?
Remember DOM doesn't like motion sickness
Domperidone, ondansetron, metoclopramide
82
What is betahistine used for?
vertigo, tinnitus hearing loss associated with Menieres disease.
83
What is the MHRA warning regarding domperidone?
```
Risk of cardiac side effects
e.g arrhythmias and QT prolongation
Maximum treatment 1 week
Recommended dose: 10mg TDS
contraindicated in cardiac + severe liver disease
```
84
What us the MHRA regarding metoclopramide?
Risk of neurological side effects such as extrapyramidal symptoms.
Use for maximum 5 days
10mg TDS
85
Which anti-emetics are dopa antagonists?
metoclopramide, domperidone
86
What are some other key ponts about metoclopramide?
- AVOID in GI obstruction
- can cause QT prolongation
- can cause dystonia (muscle spasms) common in young (esp females ) and very old. reversed with procyclidine.
87
What dose of paracetamol if the patient is under 50kg or has renal impairment.
<50kg- IV 15mg/kg max QDS.
| LFTs off- IV- max 3g a day so 1g TDS not QDS.
88
When is nefopam contraindicated?
Convulsions or when used for MI
89
What preparations do buprenorphine patches come in?
72 hourly patches
96 hourly (4 days) relvetec, transtec
7 day patches - butrans, butec
90
How long of a gap should you leave between removing buprenorphine patch and starting another opioid?
24 hours
91
What is the MHRA alert regarding codeine?
1. In children 12-18 years Max 240mg OD up to 3 days
2. Contraindicated for removal of tonsils for sleep apnoea
3. Contraindicated for breastfeeding mothers
4. Contraindicated for ultra-rapid metabolisers.
92
Whats the usual max dose of tramadol?
400mg a day
93
What is the telltale sign of cluster headaches?
How is it managed acutely and long term?
Unilateral (one sided) pain around the eye
Rarely responds to standard analgesics
1st line- sumatriptan S/c injection
2nd line- sumatriptan/ zolmitriptan nasal spray
3rd line- 100% oxygen
Refractory: prednisolone or ergotamine
If frequent or long lasting, consider prophylaxis with verapamil or lithium.
94
What is in the pink migraleve?
| What is in the yellow migraleve?
Pink- paracetamol, codeine, buclizine
| Yellow- paracetamol, codeine
95
What migraine medicine should be reduced when used concurrently with propanolol?
Rizatriptan- should be reduced to 5mg.
96
What are the requirements and dose for OTC sumatriptan?
50mg stat. can be repeated after 2 hours if needed. If no response to first dose, dont take a second dose.
maximum 100mg in 24 hours.
OTC sale:
can be sold only for diagnosed migraine
Packs of 2 P medicine , packs of 6 POM
DO NOT SELL if: on SSRI, oral contraception, SJW, heart disease risk factiors, headache lasting >24 hours and >4 headaches a month.
97
How is trigeminal neuralgia managed?
Surgery often treatment of choice
1st line- carbamazepine
(fos)phenytoin IV is useful in a crisis.
Unilateral pain from jaw upwards.
98
How should benzodiazepines be withdrawn?
Convert to diazepam first.
If short term use (2-4 weeks), withdraw over 2-4 weeks.
If long term use, reduce by 1-2mg every 2-4 weeks then by smaller intervals (0.5mg) till stop.
Can take months to over a year
99
Which benzodiazepine doses are equivalent to diazepam 5mg?
```
Nitrazepam 5mg
Lorazepam 0.5mg
Temazepam 10mg
Clonazepam 0.25mg
Chlordiazepoxide 12.5mg
```
100
Which medicines may have increased levels when you STOP smoking?
```
theophylline
cinacalcet
ropinorole
clozapine
some antipsychotics (cloz, olanzapine haloperidol)
```
101
Is the use of NRT along with varenicline or buproprion recommended?
no
102
What is a problem with 24 hour nicotine patches?
Abnormal dreams- give 16 hour patch instead.
103
What is the MHRA warning associated with varenicline?
Suicidal thoughts and behaviour
| STOP if patient develops agitation, depression, suicidal thoughts.
104
What are the concerns if a patient misses doses of their methadone/ buprenorphine?
3 days or more- risk of overdose due to loss of tolerance- consider reducing dose.
5 days or more- need assessment before restarting.
105
How long after last heroin use should methadone or buprenorphine be initiated?
methadone- 8 hours
buprenorphine-6-12 hours
24-48 hours after last use of methadone
106
What should be done if a patient on methadone becomes pregnant?
- Continue methadone, withdrawal can cause fetal death
- Buprenorphine not licensed in pregnanacy
- avoid dose reduction in first trimester, risk of miscarriage
- drug metabolism can occur in third trimester- divide dose to BD or increase.
- When breastfeeding keep dose as low as possible- monitor baby for breathing problems + sedation.
107
Which medicines can be used after alcohol withdrawal to prevent relapse ?
Acamprosate- reduce cravings
Naltrexone (C/I if recent opioid use)
Disulfram- AVOID all alcohol (even mouthwashes)- nausea arrhythmias, respiratory depression, coma
C/I in cardiac failure + suicide risk
Nalmefene- recommended if high risk of drinking (C/I if recent opioid use)
108
Which medicine can be used after opioid withdrawal to prevent relapse ?
Naltrexone
Must be clean for 7-10 days.
Contraindicated if patient is still on opioids.
blocks opioid receptors so that they don't get 'high' from opioids.
