nervous system Flashcards
name the different type of dementia
- Alzheimer’s disease (most common)
- vascular dementia (due to cerebrovascular disease)
- dementia with Lewy bodies
- mixed dementia
- frontotemporal dementia
what are the key symptoms related to dementia?
problems reasoning + communication, change in personality, reduced ability to carry out daily activities such as washing + dressing
which HCP must initate drug treatment in newly diagnosed patient vs those currently already on drug therapy?
Newly diagnosed patients: initiate drug treatment under the advice of a specialist clinician
Gp may prescribe step-up treatment
Mild to moderate Alzheimers dementia name three 1st line acetylecholinesterase inhibitors
- donepezil
- galantamine
- rivastigmine
what is the alternative treatment in mod alzheimers if acetylcholinesterase inhibitors are not tolerated or contra-indicated?
memantine (moderate disease)
moderate-severe + severe alzhimers dementia already receiving acetylcholinesterase inhibitor step up?
add memantine (may initate primary care) discontinuing acetylcholinesterase may worsen cognitive function (AVOID)
management of mild-to-mod dementia with lewy bodies (non-alzeimers)
- Donepezil [unlicensed indication]
- rivastigmine [unlicensed indication]
Alternative: If treatment with both donepezil or rivastigmine not tolerated:
- galantamine [unlicensed indication]
Alternative: in whom acetylcholinesterase inhibitors are contra-indicated/not tolerated:
- Memantine hydrochloride [unlicensed indication]
severe dementia with lewy bodies (monotherapy)
- Donepezil hydrochloride [unlicensed indication]
2. rivastigmine [unlicensed indication]
vascular dementia treatment if suspected co-morbid alzeimers, parkinsons disease dementia, or dementia with lewy bodies treament
-Acetylcholinesterase inhibitors [unlicensed indication]
OR
- memantine hydrochloride [unlicensed indication]
Which of the following are not recommended in Frontotemporal dementia or cognitive impairment caused by multiple sclerosis:
X Acetylcholinesterase inhibitors
X memantine hydrochloride
Management of cognitive symptoms of dementia - which drugs to AVOID?
Drugs cause antimuscarinic effects: cognitive impairment (AVOID)
what does cognitve symtpoms mean?
Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe.
treatment of cognitive symptoms in dementia?
depression- antidepressants e.g. amitriptyline, paroxetine
antipsychotics e.g. olanzapine, quetiapine
antihistamine= chlorphenamine, promethazine
urinary antispasmodics e.g. solifenatic, tolterodine
management non-cogntive symptoms of dementia
agitiation, aggression, distress + psychoses, depression, anxiety, sleep disturbancne
- offer counselling, CBT intial step
sleep- increase exersize and activity
antipsyhotics and antidepressants prescribing in dementia
antipsychotics- only prescribe if patient risk harming themselves, or causing severe distress,
CHM: increased risk or stroke and death with antipsychoitc + elderly patient with dementia
use lowest does + review every 6 weeks
depression- reserved those pre-existing mental health problems
what is sevre antipsychotic sensitivty reaction in those with dementia with lewy bodies or parkinson disease dementia
worsen motor feature of condition some case cause severe antipsychotic sensitivity reaction
what is the mechanism of action of acetylcholinesterases?
reversible inhibitor of acetylcholinesterase.
examples: donepezil, galantamine, rivastigmine
dopaminerigic drugs , NMDA receptor antagonist example and Mechanism of action
Memantine
DRUG ACTION =glutamate receptor antagonist
which anti-epileptics have a long half life once daily dosing?
Lamotrigine
perampanel
phenobarbital
phenytoin
Action to take if monotherapy 1st line anti-epileptic has failed?
- Try monotherapy with a second drug
* Note: Diagnosis should be checked before starting an alternative drug if the first drug showed lack of efficacy.
changing one antiepileptic to another:
BE CAUTIOUS
• slowly withdrawing the first drug only when the new regimen has been established
use of 2 or more antiepileptic (may be necessary)
• concurrent use of antiepileptic drugs increases the risk of adverse effects and drug interactions.
• If combination therapy does not bring about worthwhile benefits, revert to the regimen (monotherapy or combination therapy) that provided the best balance between tolerability and efficacy.
A single antiepileptic drug should be prescribed wherever possible.
MHRA: antiepileptics advice on switching brands
- potential harm of switching patient stabilised
- report of loss seizure, worsening SEs, explained as chance associations, casual role of switching cannot be ruled out
minimise risk of swithcing anti-epileptics brands?
3 risk categories
if desirable GP must specifiy product, prescribe brand or generic + manufacturer name
advice relates to only treatment of epilepsy
report yellow card scheme any suspected ADR
pharmacist ensure continuity of supply ,
action if a specific brand not available
it may be necessary to dispense a product from a different manufacturer to maintain continuity of treatment of that antiepileptic drug. Such cases should be discussed and agreed with both the prescriber and patient (or carer):
category 1 antiepileptics must be maintained specific manufacturer product
[CPPP] Carbamazepine phenobarbital phenytoin primidone
category 2- maintain brand based on clinical judgement, based on seizure frequency, treatment history, potential implication of patient having breakthrough seizure, + consider non-clinical factors
[CROP CEL TVZ] Clobazam rufinamide oxcarbazepine perampanel
clonazepam
Eslicarbazepine acetate
lamotrigine
topiramate
valproate
zonisamide.
category 3 (doesnt matter)- uncessary maintain specific manufacturer brand consider product name, packaging, appearance, etc + consider patient disability
[BELL TV GP] Brivaraceta ethosuximide lacosamide levetiracetam
tiagabine
vigabatrin
gabapentin
pregabalin
what is antiepileptic hypersensitivty syndrome
rare fatal syndrome associated some antiepileptics
risk of antiepileptic hypersensitivty syndrome with the following drugs
[ROLL C PPP] rufinamide oxcarbazepine lacosamide lamotrigine Carbamazepine phenobarbital phenytoin Primidone
theoretical risk:
Eslicarbazepine
stiripentol
Zonisamide
symptoms of antiepileptic hypersensitivty syndrome?
Symptoms (week 1-8 of exposure): most common: fever rash lymphadenopathy Other systemic signs: liver dysfunction Haematological renal, and pulmonary abnormalities vasculitis multi-organ failure
action to take if hypersensitivty occurs anti-epileptics
If signs or symptoms occur the drug should be withdrawn immediately!!! the patient must not be re-exposed, and expert advice should be sought
MHRA alert for all anti-epileptics
MHRA advised all antiepileptic drugs are associated with a small increased risk of suicidal thoughts and behaviour.
Symptoms may occur as early as one week after starting treatment
Advise patients to report:
• mood changes
• distressing thoughts
• feelings about suicide or harming themselves
interaction with anti-epileptics
- may increase toxicity without an increase in antiepileptic effect
- usually caused by hepatic enzyme induction or inhibition
- Displacement from protein binding sites is not usually a problem.
- Interactions are highly variable and unpredictable
antiepileptic withdrawal
withdrawn under specialist supervision
- Avoid abrupt withdrawal, particularly of barbiturates and benzodiazepines, because this can precipitate severe rebound seizures.
- Reduction in dosage should be gradual+ case of barbiturates, withdrawal of the drug may take months!
- The decision to withdraw antiepileptic from a seizure-free patient, and its timing, is often difficult and depends on individual circumstances.
- Even in patient’s seizure-free for several years, a significant risk of seizure recurrence on drug withdrawal
- In patients receiving several antiepileptic drugs, only one drug should be withdrawn at a time.
