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Inori Pre Reg > Nervous System > Flashcards

Nervous System Flashcards

1
Q

Who should use short acting benzodiazepines?

A

Elderly

Liver impairment

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2
Q

What’s the risk of short acting benzodiazepines?

A

Carries greater risk of withdrawal symptoms

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3
Q

Overdose symptoms of benzodiazepines?

A

Drowsiness, ataxia, dysarhtia, nystagmus

Worst case Respiratory depression and coma

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4
Q

Other than benzodiazepines, what other drugs are used?

A 
BBs for autonomic symptoms like palpitations
Serotonin agonist buspirone
Antidepressants
Antipsychotics
Anti epileptic like gabapentin
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5
Q

Advantage of using buspirone?

A

Low potential for abuse and dependence but takes 2wks to work

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6
Q

How does benzodiazepines work?

A

Increase GABA binding to its receptor

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7
Q

What’s the indication of benzodiazepines in anxiety?

A

Short term 2-4wks relief of anxiety that is severe, disabling or causing pt unacceptable distress

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8
Q

Side effects of benzodiazepines?

A

Paradoxical increase in hostility aggression - range from talkative news’s and excitement to aggression and antisocial acts. Increased anxiety and perceptual disorders also occur

Sedation = avoid alcohol

Dependence

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9
Q

How to avoid dependence to benzodiazepines?

A

Avoid long term use

Avoid abrupt withdrawal

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10
Q

What happens in abrupt withdrawal?

A

Toxic psychosis, confusion, convulsions and delirium like symptoms

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11
Q

Benzodiazepines withdrawal syndrome symptoms?

A

Increased anxiety, insomnia, weight loss, tremors, sweating, loss of appetite, perceptual disorders, tinnitus

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12
Q

When does withdrawal happen after using short term benzodiazepines?

A

Occurs within 3days of stopping

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13
Q

When does withdrawal happen after using long term benzodiazepines?

A

Occurs within 3wks of stopping a long acting benzodiazepines

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14
Q

How to withdraw benzodiazepines?

A
  1. Gradually covert over 1wk to equivalent diazepam dose ON
  2. Reduce diazepam dose by 1-2mg increments every 2-4wks (up to 1/10th every 1-2wks for high doses)
  3. Reduce diazepam dose further
    Can reduce in smaller steps of 500mcg towards the end
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15
Q

Which drugs will interact with diazepam to increase sedation and CNS depressant effects

A 
Alcohol
Opioids
Antihistamines
Antidepressants
Barbiturates
Antipyschotics
Z-drugs
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16
Q

Which drugs increase diazepam’s plasma conc?

A 
Amiodarone
Diltiazem
Macrolides
Fluconazole
Enzyme inhibitors
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17
Q

How long should long term treatment of bipolar disorder continue?

A

At least 2yrs from the last manic episode and up to 5yrs if the pt has risk factors for relapse

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18
Q

When should antidepressants be avoided in Co treatment of bipolar and depression?

A

Pts has rapid cycling bipolar disorder
A recent history of hypomania
Rapid mood fluctuations

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19
Q

What drug is used in initial stages of treatment for behavioural disturbance or agitation in BPD?

A

Benzodiazepines

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20
Q

What drugs are used in acute episodes of mania and hypomania?

A

Antipyschotics
Quetiapine
Olanzapine
Risperidone

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21
Q

What can be added to acute episodes of mania and hypomania if response is inadequate with Antipsychotics or if acute severe mania?

A

Lithium or sodium Valproate can be added

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22
Q

Drugs used for prophylaxis of BPD?

A

Lithium
Valproate (specialist)
Olanzapine (if there was response in manic epi)
Carbamazepine (specialist in pts unresponsive to other drugs and combo and for rapid cycling BPD)

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23
Q

What drug is licensed for the treatment of moderate to severe manic episodes associated with BPD?

A

Asenapine

A 2nd gen Antipsychotic

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24
Q

What’s a good combo of drug for pts with frequent relapses of mania and continuing functional impairment?

A

Lithium or Olanzapine as mono or additn either to Valproate

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25
Q

How long does it take for lithium to exert its full Prophylactic effect

A

6-12months after the initiation of therapy

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26
Q

Therapeutic range of lithium when used for prophylaxis or for elderly?

A

0.4-1mmol/L

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27
Q

Therapeutic range of lithium when used for treatment of acute manic episodes? Or pts who have previously relapsed

A

0.8-1mmol/L

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28
Q

When should blood sample be taken for plasma lithium monitoring?

A

12hrs post dose

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29
Q

How often should monitoring of plasma lithium level be taken place?

A

Every 3 months

Additional monitoring required if significant intercurrent illness or changes to diet or water intake

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30
Q

Why should lithium abrupt withdrawal should be avoided?

A

Higher risk of relapse

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31
Q

Signs and symptoms of lithium toxicity?

A

Revenge
R=renal disturbances (polyuria, incontinence, hypernatraemia)
E=extrapyrimidal symptoms (fine tremor, ataxia, nystagmus and muscle weakness)
V=visual disturbances
N=Nervous system disturbances (confusion and drowsiness, restlessness and in coordination)
G=GI effects (Diarrhoea and vomiting)

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32
Q

At what serum lithium conc. Does severe overdose symptoms start appearing?

A 
Over 2mmol/L
Revenge symptoms +
Renal failurr
Arrhythmia
Seizures
BP changes
Circulatory failure
Coma and sudden death
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33
Q

Lithium side effects?

A

Mild cognitive memory impairment

Thyroid disorder

Renal impairment

Benign intracranial hyoertention

QT prolongation

Lowers seizure threshold

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34
Q

Dispensing caution on lithium?

A

Prescribe by brand

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35
Q

What electrolyte imbalance predisposed lithium toxicity?

A

Hyponatraemia

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36
Q

Counselling points on lithium?

A

Maintain constant adequate salt and water intake esp in intercurrent infection, diarrhoea or vomiting dehydration

Give lithium treatment pack

Affected driving - avoid alcohol

OTC interaction like ibuprofen, soluble analgesics and antacids

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37
Q

What does the lithium treatment pack contain?

A

Contains a PIL, alert card and record book

Given when initiating treatment and mush always carry the alert card

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38
Q

Other than lithium serum conc. What should be monitored as well?

A

Renal, cardiac (ECG) and Thyroid function, BW/BMI, serum electrolytes and FBC before treatment initiation

BW/BMI, serum ELECTROLYTE, eGGR and Thyroid every 6 months

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39
Q

Is lithium safe in preg?

A

No as teratogenic
Effective contraception
Toxicity cab occur in BF infants as well

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40
Q

What drugs will increase risk of seizures if taken with lithium?

A

Quinolobes
SSRIs
Epilepsy

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41
Q

What electrolyte imbalance predisposed QT prolongation?

A

Hypokalaemia

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42
Q

What drugs when taken with lithium increases risk of extrapyrimidal symptoms?

A 
Haloperidol
Clozaoine
Phenothiazines
PD
Metoclopramide
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43
Q

What drugs when taken with lithium increases risk of neurotoxicity?

A

Phenytoin
Carbamazepine
Antiosychotics
Amitriptyline

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44
Q

What drugs when taken with lithium increases risk of Serotonin syndrome?

A 
Sumatriptan
SSRIS
MAOIs
Amfetamines
St John's wort
Tramadol
Granisetron
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45
Q

Which SSRIs case QT prolongation?

A

Citalopram and escitalopram

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46
Q

Which SSRIs has the greatest risk of withdrawal reactions?

A

Paroxetine

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47
Q

Which SSRIs is safe to use after MI and unstable angina?

A

Sertraline

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48
Q

Why are SSRIs first line as antidepressants?

A

Better tolerated and safer in overdose than other classes

TCAs have similar efficacy to SSRIs but SSRIs are Less sedating, less antimuscarnics and less cardio toxic than TCAs

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49
Q

How long does it take for SSRIs to work?

A

At least 2wks

But wait at least 4wks (6wks in elderly) before deeming it effective

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50
Q

Initial reaction to SSRIs?

A

Feel worse, increased agitation, anxiety and suicidal ideation

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51
Q

How often should you review SSRIs effectiveness at the beginning of treatment?

A

Review every 1-2wks at start of treatment

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52
Q

How long should you taken your antidepressants?

A

Continue for at least 6months (12 months in elderly) after remission
12months in generalised anxiety as has high risk of disorder
2yrs in recurrent depression

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53
Q

Second line for depression treatment?

A 
Increase SSRIs
Or
Use different SSRI
Or
Use mirtazepine

Other choices include lofepramine (TCA), moclobemide (reversible MAOI)
Or
Venlafaxine or other TCAs for more severe depression

Irreversible MAOIs under specialist

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54
Q

Third line treatment for depression?

A 
Add another antidepressant class
Or
Lithium or Antipyschotics
Or
Electroconvulsive therapy in severe
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55
Q

General side effects of antidepressants?

A

Hyponatraemia esp SSRIs and usually occurs in the elderly

Suicidal ideation and behaviour
Monitor at start of treamtnet or after dose change

Serotonin syndrome
Esp if not well withdrawal, addition of new antidepressants
Can occur within hours or days following changes or initiation

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56
Q

Serotonin syndrome symptoms?

A

Neuromuscular hyperactivity
=tremors, muscle rigidity

Altered mental state
=agitation, confusion and mania

Autonomic dysfunction
=urination, diarrhoea, hyperthermia, tachycardia, pallor, sweating, shivering

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57
Q

Washout period for MAOIs after it’s stopped?

A

Wait 2wks before switching

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58
Q

Which MAOIs does not require a washout period?

A

Moclobemide bc short acting and reversible

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59
Q

Washout period for SSRIs after it’s stopped?

A

1wk
But
2wks if sertraline
5wks if fluoxetine

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60
Q

Washout period for TCAs after its stopped?

A

1-2wks
But
3wks if imipramine or clomipramine

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61
Q

When do antidepressants withdrawal reactions occur?

A

Within 5 days of stopping

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62
Q

The risk of withdrawal reactions is increased if

A

If antidepressants stopped suddenly after taking for 8wks or morr

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63
Q

Higher risk of antidepressants withdrawal reaction with which drugs?

A

Paroxetine

Venlafaxine

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64
Q

Side effects of SSRIs?

A

GASH
G=GI disturbances like N&V, diarrhoea
A=appetite or weight disturbance (gain or loss)
S=Serotonin syndrome
H=hypersensitivity reactions = stop if rash occurs

Others include
Bleeding risk increased
QT interval prolongation with citalopram and escitalopram
Seizure threshold lowered
Movement disorder and dyskinesia
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65
Q

Overdose symptoms of SSRIs?

A 
N&V
agitation
Tremor
Nystagmus
Drowsiness
Sinus tachycardia
Convulsions
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66
Q

Juice that increases SSRIs cocn?

A

Grapefruit juice as an enzyme inhibitor

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67
Q

What drugs increase risk of bleeding when given with SSRIs?

A

NSAIDs /aspirin
Anticoagulant
Antiplatelets
Warfarin

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68
Q

Dose of TCAs?

A

ON

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69
Q

When are sedating TCAs given to pts?

A

Given in anxious agitated pts

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70
Q

Sedating TCAs?

A 
Amitriptyline
Clomipramine
Dosulepin - dangerous in overdose so specialist use
Doxepin
Trimipramine
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71
Q

When are Less sedating TCAs given.?

A

Given in withdrawn apathetic pts

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72
Q

Less sedating TCAs?

A

Imipramine
Lofepramine
Nortriptyline

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73
Q

TCA with the most antimuscarnic effect?

A

Imipramine

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74
Q

TCA with the most hepatotoxicity?

A

Lofepramine

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75
Q

Tetracycline antidepressants?

A

Sedating as well
Mianserim
Trazodone

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76
Q

Side effects of TCAs?

A

TCAS
T=TCAs are more sedating, more epileptogenic, more cardio toxic, more antimuscarnic than SSRIs
C=cardiac side effects like QT prolongation, arrhythmia, heart block and hypertention
A=antimuscarnics
S= seizures

Others
Hallucinationsmania
Hypotention
Sexual dysfunction
Breast changes
Extrapyrimidal side effects
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77
Q

Symptoms of antimuscarnic side effects?

A 
Dry mouth
Blurred vision
Constipation
Tachycardia
Urinary retention
Pupil dilation
Raised Intra ocular pressure
Glaucoma
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78
Q

Drugs of irreversible MAO-B inhibitors?

A

Only prescribed under specialist = phobic pts and depressed pts with atypical hypochondriacal or hysterical features are said to respond best to MAOIs

Phenelzine
Isocarboxazid
Tranylcypromine

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79
Q

MAOIS that are most hepatotoxic?

A

Phenelzine

Isocarboxazid

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80
Q

Drugs of reversible MAO-A inhibitors

A

Moclobemide

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81
Q

MAOIS with the greatest stimulant effect?

A

Tranylcypromine

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82
Q

MAOIS that are most likely to cause a hypertensive crisis?

A

Tranylcypromine bc it has the greatest stimulant effect

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83
Q

Response time to MAOIS?

A

3wks or more and may take an additional 1-2wjs to become maximal

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84
Q

Side effects of MAOIS?

A

Hepatotoxicity
Postural hypotention /hypertensive response
=discontinue if palpitations or frequent headaches occur

Hypertensive crisis
=discontinue if throbbing headaches occur

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85
Q

Drugs that can cause hypertensive crisis when Co administered with MAOIS?

A 
Pseudoephedrine
Adrenaline
Noradrenaljne
Levodopa
Anything dopamine
TCAs esp Tranylcypromine and clomipramine
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86
Q

Food interactions of MAOIS?

A

Tyramine rich food
Eat only fresh food and avoid stale
Avoid alcohol

Food and drug interaction can exist 2wks after stopping an irreversible MAOIS

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87
Q

Washout periods on MAOIS?

A

Other antidepressants should not be started for 2wks after MAOIs
3wks if starting clomipramine or imipramine

MAOIs should not be started at least 2wks after previous MAOIS
At least 1-2wks after TCA (3wks in case of clomipramine or imipramine)
At least a week after an SSRIs (5wks in case of fluoxetine)

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88
Q

Management of acute anxiety?

A

Benzodiazepines or buspirone (Serotonin agonist)

don’t use together, withdraw benzo first if wanna use buspirone

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89
Q

Treatment for chronic anxiety

A

Longer than 4wks

Antidepressant like SSRIs and SNRI (Duloxetine and Venlafaxine)

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90
Q

Last resort for anxiety management?

A

Pregabalin

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91
Q

Treatment for panic disorder?

A

1st line is SSRIs

2nd line is clomipramine or imipramine

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92
Q

Treatment for OCD?

A

1st line SSRIs

2nd line clomipramine

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93
Q

Treatment for Ptsd

A

SSRIs

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94
Q

Treatment for phobia like social anxiety disorder?

A

1st line SSRIs

2nd line for social anxiety disorder is moclobemide

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95
Q

Treatment of inappropriate sexual behaviour?

A

Benperidol an 1st gen Antipsychotics

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96
Q

What electrolyte imbalance increases lithium toxicity?

A

Sodium depletion Hyponatraemia

So avoid thiazide and loops

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97
Q

Schizophrenia has 4 dopamine pathways

Name each one

A

Underactivitg in mesicorticol pathway
=negative symotoms (catatonia. Social withdrawal, apathy)

Over activity in mesolimbic oathway
=positive symptoms (hallucinations, delusions)

D2 antagonism in nigrostriatal oathway
=extrapyrimidal symptoms

D2 antagonism in tuberofundibula pathway
=hyperprolactinaemia
(Menstural disturbances, galactirrhoea, gynaecomasta, sexual dysfunction)

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98
Q

How to increase Antipsychotics dose?

A

Slowly and once weekly

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99
Q

High dose therapy of Antipsychotics should only continue for?

A

Limited period only and review regularly

Stop if there is no improvement after 3 months

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100
Q

Important advice on administration of Antipsychotics drugs in an emergency like psychotic episode?

A

If administered via IM route, dose should be lower than oral dose esp for active pts bc increased blood flow

Prescription should specify dose for each route

Review emergency dose of Antipyschotics at least daily

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101
Q

Elderly pts are particularly susceptibile to which side effects?

A

Postural hypotention and hyper/hypothermia in hot or cold weather

102
Q

Initial dose of Antipsychotics in elderly should be?

A

Half the adult dose

103
Q

1st generation Antipsychotics mode of action?

A

Blocks D2 receptors in the brain

Not selective for any of the 4 dopamine pathways so can cause range of side effects

104
Q

Phenothiazines general side effects?

A

Hepatotoxic and cause acute dystonic rractions

105
Q

Group 1 of Phenothiazines side effect?

A

Most sedative

Chlorpromazine
Levomeoromazine
Promazine

106
Q

Chlorpromazine ‘s specific side effect?

A

Contact sensitisation

107
Q

Advantage of group 2 Phenothiazines?

A

Least EPS

Pericyazine

108
Q

Group 3 Phenothiazines side effecr

A 
Most EPS
Fluphenazine
Perphenazine
Prochlorperazine
Trifluoperazibe
109
Q

Butyrophenones side effect? And drugs?

A

Benperidol

Haloperidol causes QT prolongation and is similar to group 3 Phenothiazines being most EPS

110
Q

Thioxanthenes drug names and side effects?

A

Flupentixol should not be taken in the evening
Zuclopenthixol has depot preparation and can be used in agitated and aggressive pts and more effective in preventing relapses

111
Q

Other 1st gen antupsychotics?

A

Pimozide can cause QT prolongatiom
Sulpiride
=both have reduced sedative, antimuscarnic and EPS

Loxapine cause bronchospasm

112
Q

Mode of action of 2nd gen Antipsychotics?

A

Blocks D1 to D4 receptors

113
Q

Advantage and disadvantage of 2nd gen compared to 1st gen

A

Maybe more effective at treating negative symptoms
But
More metabolic side effects

114
Q

Side effect of amisulpride

A

Most hyperprolactinaemia

115
Q

Advantage of aripiorazole?

A

Does not cause hyperprolactinaemia

116
Q

Side effect of Olanzapine?

A

Most weight gain and diabetes

117
Q

Side effect of Risperidone?

A

Most hyperprolactinaemia

118
Q

Which 2nd gen Antipsychotics is the most effective?

A

Clozapine

119
Q

What anti psychotic is the most effective?

A

Clozapine

120
Q

Clozapine license?

A

Licensed for resistant schizophrenia

Tried 2 or more drugs Inc 2nd gen for at least 6-8wks each

121
Q

How long should clozapine be tried for?

A

8-10wks
If symptoms do not respond to an optimised dose, measure plasma clozapine levels before augmenting with 2nd anti psychotic drug

122
Q

What to do with clozapine missed dose?

A

If more than 2, reinitiate by specialist

123
Q

Most important interactions to note with clozapine?

A

Increased risk of agranulocytosis (blood dyscrasias)

Aminosalicylate, Immunosuporessants like methotrexate and cytotoxic drugs

124
Q

Side effects of clozapine?

A

MAG
M=myocarditis and cardiomyopathy
Persistent tachycardia, esp in first 2 months, stop permanently if it occurs
A=agranocytosis and neutropenia
G=GI obstruction
Intestinal peristalsis Impaired so constipation, faecal impaction

125
Q

MHRA warning on clozapine?

A

Potentially fatal risk of intestinal obstruction, faecal impaction and paralytic ileus

  • report constipation before taking next dosr
  • take caution with constipation meds e g. Hyoscine used to treat hypersalivation with clozapine
126
Q

Which Antipsychotics most commonly cause EPS?

A

Pipeazind phenothiazines
The butyrophenones (haloperidol)
1st gen depot preparations

127
Q

What does dystonia mean?

A

Abnormal face and body movements

128
Q

What does dyskinesia mean?

A

Involuntary erratic movements of the face, arms, legs or trunk

129
Q

What does akathisia mean?

A

Restlessness

Characteristically occurs after large initial doses of Antipsychotics

130
Q

What does tardive dyskinesia mean?

A

Rhythmic, involuntary movements of tongue, face and jaw

Which usually develops on long term therapy or with high doses of Antipsychotics

131
Q

Which EPS symptoms is the most serious?

A

Tardive dyskinesia because it can be irreversible sometimes even on withdraw and treatment is usually ineffective

132
Q

How do both gens of Antipsychotics increase prolactin conc?

A

Antipsychotics decrease dopamine conc.

Dopamine inhibits prolactin release so as reduce dopamine, no inhibitions and thus increased prolactin

133
Q

Which Antipyschotics reduces prolactin and why?

A

Aripiorazole bc it’s a dopamine receptor partial agonist

133
Q

Which Antipyschotics reduces prolactin and why?

A

Aripiorazole bc it’s a dopamine receptor partial agonist

134
Q

Which Antipsychotics are most likely to cause hyperprolactinaemia?

A

1st gen
Risperidone
Amisulpride

135
Q

Symptoms of Hypercholestrrolaemia?

A 
Sexual dysfunction
Reduced bone mineral density
Menstural disturbances
Breast enlargement
Galactirrhoea
136
Q

Which Antipsychotics commonly cause sexual dysfunction?

A

Sexual dysfunction

137
Q

CV side effects of Antipsychotics?

A

Tachycardia, arrhythmia and hypotention

QT interval prolongation

138
Q

Which Antipsychotics have high probability of causing QT prolongation?

A

Pimozide and haloperidol

IV Antipsychotics

139
Q

All Antipsychotics may cause weight gain but which one in particular are a concern?

A

Clozapine and Olanzapine commonly cause weight gain

Clozaoine, olanzaoine, Quetiapine and Risperidone may cause hyperglycaemia /diabetes

140
Q

Which Antipsychotics cause postural hypotension? Esp during initial dose titration?

A

Clozapine, chlorpromazine, lurasidone and Quetiapine

141
Q

Symptoms of neuroleptic malignant syndrome?

A 
Hyoerthermia
Fluctuating levels of consciousness
Muscle rigidity
Autonomic dysfunction with pallor
Tachycardia
Labile blood oressure
Sweating
Urinary incontinence
142
Q

Neuroleptic malignant syndrome can continue for how long even after drug discontinuation?

A

5-7days.

May be unduly prolonged if depot preparations are used

143
Q

Which generation of Antipsychotics are better at treating the negative symptoms of schizophrenia?

A

Second generation

144
Q

Which Antipsychotics are least likely to cause EPS and thus are used if pts can’t tolerate EPS?

A

2nd gen

Aripiorazole, clozapine, Olanzapine and Quetiapine

145
Q

Which Antipsychotics are least likely to cause QT prolongation?

A

Aripiorazole the least

Amisulpride, clozapine, flupentixol, Fluphenazine, Olanzapine, Perphenazine, Prochlorperazine, Risperidone and Sulpiride

146
Q

Which Antipyschotics has the lowest risk of sexual dysfunction?

A

Aripiorazole and Quetiapine

Clozaoine and Olanzapine next bc not significant hyperprolactinaemia

147
Q

Pt should receive an Antipyschotics for how long before deeming it ineffective

A

4-6wks

148
Q

How long should clozapine used for to assess response?

A

8-10wks

149
Q

Pt needs to register with what service in order to use clozapine?

A

Clozapine pt monitoring service

150
Q

What monitoring is required with Antipyschotics at the start of therapy then annually thereafter?

A 
FBC
Urea
Electrolytes
LFTs
ECG
151
Q

What should be measure when using Antipsychotics at baseline, at 3 months then yearly?

A

Blood kipids

Weight

152
Q

What should be measured before using Antipsychotics and frequently during titration?

A

BP

153
Q

What Antipsychotics can be used for intractable hiccups?

A

Chlorpromazine and haloperidol

154
Q

Psychomotor agitation should be investigated for an underlying cause but it can be managed with what drugs?

A

Low doses of chlorpromazine or haloperidol for short term

155
Q

Depot flupentixol dose interval?

A

2wks

156
Q

Depot Fluphenazine dose interval?

A

2wks

157
Q

Haloperidol depot dose interval?

A

4wks

158
Q

Zuclopenthixol depot dose interval?

A

2wks

159
Q

Dose advice on depot Antipsychotics?

A

Give a test dose as undesirable effects are prolonged with depots
Give oral Antipyschotics whilst stabilising on depot preparation
Depot preparation typically end in decanoate

160
Q

Important safety info on depot?

A

Do not confuse with other oreoo
IM haloperidol decanoate is used for maintenance therapy whereas IM haloperidol is used for rapid control in acute episodes

161
Q

Antipsychotics need to be stopped at first sign of tardive dyskinesia which is?

A

Fine vermicular movement of tongue

162
Q

What needs to be monitored at start, 6monthd and the yearly for antupsychotics?

A

Prolactin levels

163
Q

There are multiple mechanisms for sexual dysfunction

What happens if you block D receptors?

A

Hyperprolactinaemia and low libido

164
Q

There are multiple mechanisms for sexual dysfunction

What happens if you block M receptors?

A

Arousal disorder

165
Q

There are multiple mechanisms for sexual dysfunction

What happens if you block alpha 1 receptors?

A

Erectile dysfunction and ejaculatory problems

166
Q

Side effects of Antipsychotics apart from the main ones?

A 
Antimuscarnics side effects
Blood dyscrasia
Photosensitivity in high doses
Jaundice
Sedation
167
Q

Which Antipsychotics prolongs QT interval and cause sudden death?

A

Pimozide

168
Q

What is labyrinthitis?

A

Inner ear infection

169
Q

Management of nausea and vomiting in the first trimester?

A

No drug treatment required bc generally mild

170
Q

Management of severe vomiting in preg?

A

1st line: Short term treatment with promdthazine

Alternatives: Prochlorperazine or Metoclopramide

If symptoms do not settle in 24 to 48hr, then seek specialist

171
Q

Name of Phenothiazines and how they are used for nausea?

A

Prophylaxis and treatment of N&V associated with diffuse neoplastic disease, radiation sickness and emesis caused by Opioids and general anaesthetics and cytotoxics
Mainly post operative

Prochlorperazine
Perphenazine
Chlorpromazine
Trifluoperazine

172
Q

Perphenazine and Trifluoperazinr are less what than chlorpromazine？

A

Less sedating

173
Q

Other than Phenothiazines, what other Antipsychotics are used in nausea and its specific uses?

A

Haloperidol and Levomeoromazine are used in palliative care

Droperidol for post operative

174
Q

Prophylaxis of motion sickness?

A

1st line: hyoscine hydrobromide

The sedating antihistamines are less effective but better tolerated
2nd line: promethazine (if sedation required)
Cyclizine or cinnarizine is preferred
Antihistamines are also used in vertigo

175
Q

Metoclopramide’s mode of action?

A

Antagonised D2 receptors in CTZ
Also acts directly on gut to promote gastric emptying and has prokinetic effect so superior compared to Phenothiazines for emesis associated with gastroduodenal, hepatic and biliary diseass

176
Q

MHRA warning on Metoclopramide?

A

Risk of neurological adverse effects so restricted duration (max 5days), age restrictions (18 plus)

177
Q

Dose of Metoclopramide and max dose?

A

10mg TDS

Max 500mcg/kg

178
Q

Side effects of Metoclopramide?

A

Acute dystonic reactiobs
=facial and skeletal muscle spasms and oculogyric crisis (瞳孔が上を向く)(more common in young, esp girls and young women and in very old)

179
Q

What drug can be used to abort dystonic attacks?

A

Procyclidine (anti parkinsonian drug)

180
Q

Interactions between Antipyschotics and Metoclopramide?

A

Increased EPS

181
Q

Parkinsons disease and Metoclopramide interaction?

A

Metoclopramide exacerbates PD so caution

182
Q

How does domperidone work?

A

Antagonised D2 receptors in CTZ

Like metoclooramide, also acts directly in gut to promote gastric emptying, prokinetic effect

183
Q

MHRA warning on domperidone?

A

Risk of cardiac side effect (QT prolongation, arrhythmia, sudden death)

  • so should only be used for N&V
  • used at the lowest effective dose of no longer that a week
  • contra indicated for use in underlying cardiac disease, drugs that QT prolongation, enzyme inhibitors and severe hepatic imapirment
184
Q

Dose of domperidone?

A

10mg TDS for adult 12+ and over 35kg

185
Q

Choice of antiemetic in PD?

A

Domperidone

Bc doesn’t cross the BBB so doesn’t cause EPS

186
Q

Drugs of 5HT3 receptor antagonists?

A

Ondansetron
Granisetron
Palonosetron

187
Q

Use of ondansetron and Granisetron?

A

For symptomatic relief of post operative N&V

Chemotherapy induced nausea vomiting

188
Q

Use of Palonosetron?

A

Prevention of N&V associated with moderately or highly emrtogenic cytotoxic Chemotherapy e.g. Cisplatin based

189
Q

Side effects of 5HT3 receptor antagonists?

A

QT prolongation

190
Q

Results of interaction between ondansetron and diuretics, steroids, SABA, theophylline, stimulant laxatives abuse, amphiterucin?

A

Increased risk of torsade de pointes with Hypokalaemia

191
Q

Results of interaction between ondansetron, sumatriptan,MAOIS, SSRIS?

A

Serotonin syndrome

192
Q

Which steroid has antiemetic effects and is used in vomiting associated with cancer Chemotherapy?

A

Dexamethasone

193
Q

What synthetic cannabinoid has antiemetic properties and is used for N&V caused by cytotoxic Chemotherapy that is unresponsive to conventional antiemetic?

A

Nabilone

194
Q

Antiemetic that are used for Chemotherapy and can be combined with dexamethasone and ondansetron?

A

Aorepitant
Fosapreoitant
Rolapitant

195
Q

Which antiemetic cross the BBB and cause dopamine blockage and thus should not be used in PD?

A

Metoclopramide, haloperidol, Prochlorperazine

196
Q

What can happen if you abruptly withdraw anti parkinsons drugs?

A

Acute akinesia

Neuroleptic malignant syndrome

197
Q

What’s the cause of PD?

A

Death of dopaminergics cells of the substantial nigra in the brain

198
Q

Non drug treatment of PD?

A

Physiotherapy if balance or motor function problems are present

Speech and language therapy if communication, swallowing or saliva problems

Occupational therapy if difficulties with daily activities

199
Q

What’s first line for PD with motor symptoms that decrease their QoL?

A

Levodopa

200
Q

Levodopa drug combinations?

A

Co-beneldopa
= benserazide

Co-careldopa
=carbidopa

201
Q

Drugs used for PD with motor symptoms that do Not affect QoL?

A 
Levodopa
Or
Non ergot derived dopamine receptor agonists
Or
MAO-B inhibitors
202
Q

Drugs of non ergot derived dopamine receptor agonists?

A

Pramipexole
Ropinirole
Rotigotibe

203
Q

Drugs of MAO-B inhibitors?

A

Selegiline (metabolised to amphetamine)

Rasagiline

204
Q

When to start using adjuvant therapy in PD?

A

Pts who develop dyskinesia or motor fluctuations despite optimal Levodopa therapy

205
Q

Choices of adjuvant therapy?

A

Non ergot derived dopamine receptor agonists
Or
MAO-B inhibitors
Or COMT inhibitors

206
Q

Drugs of COMT inhibitors?

A

Entacapone

Tolcapone

207
Q

Ergot derived dopamine receptor agonists aren’t really recommended but when can they be used?

A

If inadequate response with non ergot derived dopamine receptor agonists

208
Q

If dyskinesia aren’t adequately managed by other drugs, what’s last resort?

A

Add amantadine is adjuvant

209
Q

What’s amantadine?

A

A weak dopamine agonist

210
Q

Management off advanced PD?

A

Apomorohine via SC intermittent injections or continuous infusion

211
Q

How to manage N&V caused by apomorohine?

A

Start domperidone 2 days before apomorohine treatment and discontinue as soon as possible

212
Q

MHRA advice on domperidone and apomorohine treatment?

A

Both cause QT interval prolongation and cause serious risk of arrhythmia so assess cardiac risk factors, monitor ECG and ensure benefits outweigh risks when initiating treatment

213
Q

Drug choice for advanced Levodopa responsive PD with severe motor fluctuations, hyperkinesia or dyskinesia

A

Levodopa carbidopa intestinal gel administered with a portable pump directly into the duodenum or upper jejunum

214
Q

Last resort for advanced PD where drug treatment had failed?

A

Deep brain stimulation

215
Q

MoA of Levodopa?

A

Levodopa is the amino acid precursor of dopamine and acts by replenishing depleted dopamine levels in the brain

216
Q

Side effects of Levodopa?

A

Impulsive control disorders
(gambling, hypersexuality, binge eating, obsessive shopping)

Excessive sleepiness and sudden onset of sleep (so no driving)

Motor complications
(dyskinesia=involuntary muscle movements, response fluctuations)

End of dose deterioration with shorter length of benefit
So switch to MR?

217
Q

What’s the drug group name of carbidopa and benserazide? And its function?

A

Peripheral dopa decarboxylase inhibitors
They help to reduce side effects like N&V and CV effects
Also reduces dose requirements for therapeutic effect

218
Q

What drugs are considered as dopamine receptor agonsits?

A

Non ergot derived dopamine receptor
Ergot derived
Apomorohine
Amantadine

219
Q

Disadvantage of dopamine agonists compared to Levodopa?

A

Associated with more hallucinations, excessive sleepiness and impulse control disorders

220
Q

Side effects of ergot derived dopamine receptor agonists limit their use. What are they?

A

Fibrotic recations (scarring, thickening tissues)

  • pulmonary (dyspnoea, persistent cough)
  • retro peritoneal (abdominal pain and tenderness)
  • pericardial (cardiac failure)
221
Q

Side effects of dopamine receptor agonists?

A

Impulsive control disorder

Excessive sleepiness and sudden onset of sleep

Psychotic symptoms like hallucinations and delusions

Hypotensive reactions in the first few days

222
Q

MoA of MAO-B inhibitors?

A

Inhibit monoamine oxidase B enzymes which are responsible for the breakdown of monoamines=dopamine

223
Q

Important interactions of MAO-B inhibitors?

A

Hypertensive crisis with pseudoephedrine, phenylephrine, xylometazoline, oxgmetazoljne (OTC nasal decongestants)
Adrenaline, Noradrenaline, amphetamines, B2 agonists

224
Q

MoA of COMT inhibitors?

A

Preventing the peripheral breakdown if Levodopa by inhibiting catechol-O-methyltransferase, allowing more Levodopa to reach the brain

225
Q

Important interactions of COMT inhibitors?

A

Increased CV effects with adrenaline, Noradrenaline, MAOIs, Tranylcypromine

226
Q

Side effect of entacapone?

A

Colours urine reddish brown

227
Q

Side effect of Tolcapone?

A

Hepatotoxicity

228
Q

Signs of liver toxicity?

A 
Anorexia
N&V
Abdominal pain
Dark urine
Pruritus
229
Q

What can be used to manage daytime sleepiness caused by PD

A

Modafinil

Review treatment at least every 12 months

230
Q

Management of postural hypotention caused by PD

A

Midodrine is first line

Fludrocortisone unlicensed alternative

231
Q

Management of psychotic symptoms caused by PD

A

Quetiapine first line

Clozapine

232
Q

Management of rapid eye movement sleep behaviour disorder in PD?

A

Clonazepam
Melatonin
Both unlicensed

233
Q

Management of drooling of saliva in PD?

A

Glycooyronnium is first line
Botulinum toxin type a is second

Antimuscarnics not recommend because of its cognitive adverse effects

234
Q

What’s the important safety info of metoclooramide?

A

Can cause severe EPS particularly in young adults

235
Q

Different types of insomnia?

A

Transient insomnia
=caused by environmental factors like noise, shift work, jet lag

Short term insomnia
=related to emotional problem or a serious medical illness
May last a few weeks and may recur

Chronic insomnia
=commonly caused by Psychiatric disorders like anxiety and depression
Other cause include pain, dyspnoea and Pruritus

236
Q

When is it suitable to use short actin hypnotics for insomnia?

A

When Sedation the following day is not desirable

Elderly pts

237
Q

When is it suitable to use long a ting hypnosis for insomnia?

A

Pts with poor sleep maintenance like they wake up early etc

238
Q

Treatment for transient insomnia?

A

Short acting rapidly eliminated hypnotics

Only give one or 2 doses

239
Q

management of short term insomnia?

A

Give no more than 3wks of hypnotics preferably only for 1 wk

Best to take intermittently and omit some doses

240
Q

Management of chronic insomnia

A

Treat underlying cause

If depression is the cause, could use sedating treatment like mirtazepine or clopipramine

241
Q

Which short term benzodiazepines are used as hypnotics for insomnia?

A

Nitrazepam
Flurazepam
Diazepam

242
Q

Which benzodiazepines are given as short acting hypnotics?

A

Lorazolam
Lormetazepam
Temazepam

243
Q

Duration of use with z drugs?

A

Up to 4wks
2wks if zalepon
For severe insomnia that interferes with daily life

244
Q

Side effects of Z drugs?

A

Paradoxical effects - adjust dose

Daytime sleepiness - avoid alcohol

245
Q

How long does it take to develop tolerance to z drugs and benzodiazepines?

A

3_14days of continuous use.

246
Q

What drug used for insomnia is suitable for elderly because no hangover effect?

A

Clomethiazole

247
Q

What is Melatonin and its license?

A

A pineal hormone

Licensed for short term treatment of insomnia in adults over 55

248
Q

What is narcolepsy?

A

Rare long term brain disorder that causes a person to suddenly fall asleep at inappropriate times

249
Q

Treatment of narcolepsy?

A 
Modafinil 
Methylphenidate (CD2)
Dexamfetamine (CD2)
Sodium oxybate (CD2)
Pitolisant

Inori Pre Reg (22 decks)

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