Neuro - My Flash Cards
What age of onset for a new headache is a red flag? And why?
Over 50 years
Temporal arthritis (giant cell arthritis) - particularly if uni-lateral headache in temporal region of brain
What can a thunderclap headache be a symptom of? Does this require referral?
Haemorrhage, stroke or aneurism
Refer to A+E / 999
Apart from a sudden onset of head pain, what are the symptoms of haemorrhage/aneurysm?
Nausea and vomiting
Stiff neck
Photophobia
Why should you refer if a patient taking CPCs experiences an aura for the 1st time?
Increased risk of stroke with COCs and migraine
What can the symptoms of red eyes with a halo be a sign of?
Acute glaucoma - refer to GP or optician/ ophthalmologist
What is temporal arthritis/giant cell arthritis? How is it treated?
Chronic vasculitis characterised by inflammation in the arteries
Medical emergency! Refer and treat with glucocorticoids initially
What is 1st line for focal seizures?
Lamotrigine or levetiracetam
What is second line for focal seizures?
Carbamazepine, oxcarbazepine or zonisamide
What is 1st line for absence seizures?
Ethosuximide
What is 2nd line for absence seizures?
Sodium valproate
If woman of child-baring age then lamotrigine
What anti-epileptics should not be used in absence or myoclonic seizures?
Carbamazepine
oxcarbazepine,
phenytoin,
phenobarbital,
tiagabine,
vigabatrin,
gabapentin and pregabalin
What is 1st line for myoclonic seizures?
Sodium valproate
Levetiracetam for women of child-baring age
What are the key side effects of phenytoin including signs of overdose?
Overdose: nystagmus, slurred speech, tremor, confusion
Other side effects:
Skin rashes
Bradycardia and hypotension with IV
Bone marrow suppression (due to anti-folate effects)
Increase vitamin D metabolism = osteoporosis
Arrhythmias due to blocking Na+ in the heart
Which antiepileptics have a long half life and therefore can be given once daily?
Phenytoin
Phenobarbital
Perampanel
Lamotrigine
However - tend to split large doses to avoid high peak plasma concentration
Most antiepileptics are given twice a day
How are phenytoin levels monitored?
After IV loading take levels 2-4 hours post dose then monitor every 24 hours until stabilised
Pre-dose (trough) level to be taken 5 days after starting maintenance treatment or any dose changes
Then a second sample after 5-10 days as further accumulation may occur (due to long half life)
Apart from drug levels, what else should be monitored when a patient is on phenytoin?
U+Es, LFTs, FBC and vitamin D levels
(ECG if IV)
Do you dilute phenytoin IV
You can but there is a risk of precipitation- therefore give through 5micron filter
If giving neat - high risk of extravasation so give slowly through peripheral vein
What are the cautions around enteral feeding and phenytoin?
Phenytoin reacts with feed therefore allow 2 hour feed break pre-and post drug administration
Which anti-epileptics are cautioned in the HLA-B allele? Which population are most at risk?
Carbamazepine: pre-treatment screening required for Han Chinese or Thai
Risk of SJS
Phenytoin to a lesser extent - no pre-screening required
Which anti-epileptics are cautioned in the HLA-A allele? Which population are most at risk?
Carbamazepine - no pre-screening required but increased risk of cutaneous reactions in European and Japanese origin
What is neuroleptic malignant syndrome?
Life threatening neurological disorder characterised by confusion, fever and rigidity
What are the key interactions for lamotrigine?
Carbamazepine - decreased levels of lamotrigine
COCs - decreased levels of lamotrigine
Sodium valproate - increased levels of lamotrigine (reduce dose and monitor for rash)
Desmopressin - hyponatraemia (monitor sodium)
Which antiepileptic can cause pancreatitis?
Sodium valproate
What are the main counselling points for sodium valproate?
PPP (women)
Blood or hepatic disorders
Pancreatitis signs : nausea and vomiting, abdominal pain
What antibiotic ass should be avoided when taking sodium valproate?
Carbapenems - increased clearance of valproate = risk of seizures
What changes are being made the the PPP for valproate in summer 2023?
Will include:
Men <55
Men > 55 of chance of conceiving (e.g. fertile spouse)
What are the highly effect forms of contraception for PPP?
Long acting reversible methods:
Copper coil
IUD
Progesterone implant (IMP)
Sterilisation
If using other methods, use 2 forms e.g. COCs plus barrier
How is levetiracetam cleared?
Renally - dose restrictions if eGFR <80ml/min
What is the major side effect of levetiracetam?
Neuropsychiatric effects:
Depression (suicidal ideation - report)
Irritability
Aggression
Psychosis
What are the common side effects of levetiracetam?
Sedation
Confusion
Weight changes
Visual disturbances
What is cannabidiol (CD2) licenced for?
Lennox-gastaut syndrome
Dravet’s syndrome
(In combination with clobazam)
What are some examples of non-ergot derived dopamine agonists?
Ropinirole
Rotigotine
Pramipexol
Apomorphine
What is the safety warning for dopamine agonists?
Impulse control disorders e.g. gambling, binge eating, hyper-sexuality
What class of drug are selegilline, rasagiline, as safinamide?
MAO-B inhibitors
What is the treatment for daytime sleepiness in Parkinson’s after non-pharmacological measures?
Modafinil (not in pregnancy)
Review every 12 months
What can be used to treat hallucinations in Parkinson’s?
Quetiapine if no cognitive impairment
Clozapine as alternative
What is 1st like for Parkinson’s disease dementia?
Rivastigmine (only UK licenced AChEi)
Donepezil, galantamine and rivastigmine are off label
Memantine only considered if others are not tolerated or contraindicated
What can be used to control drooling of saliva in Parkinson’s disease?
Glycopyrronium
Botulinum toxin A
Topical atropine (if low risk of cognitive impairment)
What are the pro-cholinergic side effects?
Sweating
Diarrhoea
Abdominal cramps
Urinary incontinence
What conditions should AChEi be cautioned in?
Asthma / COPD
Bradycardia or condition disease
GI ulceration
Epilepsy (rivastigmine)
What are the 3 AChEi used in dementia?
Donepezil
Rivastigmine
Galantamine
Which AChEi is licenced in Parkinson’s Disease dementia?
Rivastigmine (capsules only - patches not licenced)
Which type of dementia should AChEi not be used in?
Frontal- temporal
(Vascular - they should only be used if they have suspected co-morbid AD, PD dementia or Lewy body dementia)
When should memantine be used 1st line?
Severe Alzheimer’s disease
Which SSRI has a high cholinergic burden?
Paroxetine
Which drug for urinary incontinence has the lowest cholinergic burden?
Mirabegron
Which antipsychotic has the lowest cholinergic burden?
Aripiprazole
What is 1st line for non-Alzheimer’s dementia?
Donepezil or rivastigmine
(Consider galantamine if others not tolerated)
What class is memantine?
NMDA antagonist (prevents calcium influx therefore blocks excitotoxic cell death)
What are the side effects of memantine?
Constipation
Hypertension
Dyspnoea
Can aggravate depression and cause seizures (rare)
What conditions are cautioned with memantine?
Epilepsy
Severe hepatic impairment (avoid)
Renal impairment (adjust dose)
What can be used for postural hypotension in Parkinson’s disease?
Midodrine
What can be used for advanced Parkinson’s disease (can cause nausea therefore is given with domperidone)?
Apomorphine (injection or infusion)
However - risk of QT prolongation with domperidone therefore ECG monitoring required
For bus, coach and lorry drivers, how long following a 1 off seizure can they reapply for a licence?
5 years (and taking no epilepsy medications)
For bus, coach or lorry drivers, how long following multiple seizures can they reapply for a licence?
10 years (not taking epilepsy medication)
For normal drivers, how long following your 1st seizure can you reapply for a licence?
6 months (providing medical advisors happy)
How long is your driving licence taken away when you have a seizure?
12 months
6 months if the seizure was due to a change in epilepsy medication and you have returned to previous regime / dose
Which SSRI has the shortest half life?
Paroxetine (stop slowly over several weeks)
Which SSRI causes the worst GI side effects?
Sertraline
Which SSRIs have the highest incidence of side effects? (3)
Fluoxetine, fluvoxamine, and Paroxetine
What are the most common side effects of mirtazepine? (2)
Sedation and weight gain
What are the most common side effects of SSRIs?
Nausea and sexual dysfunction
How long should you take an antidepressant for?
6 months following 1st bout
1-2 years following relapse
3-5 years if multiple relapses
What is the drug treatment for GAD?
SSRI
Different SSRI/SNRI
Pregabalin
Continue for 1 year
What is the drug treatment for PTSD?
Venlafaxine (off label) or SSRI (sertraline or Paroxetine licenced)
Consider antipsychotics e.g. risperidone
Continue for 12 months
What is the drug treatment for panic disorder?
SSRI
imipramine or clomipramine (TCA)
Continue for 6 months
What is the drug treatment for social anxiety disorder?
SSRI (escitalopram or sertraline)
Different SSRI (fluvoxamine) or SNRI
MAOI (phenelyzine or moclobemide)
Continue for 6 months
What should be used to treat insomnia if over 55 years?
MR melatonin for maximum of 13 weeks
Which benzodiazepines are best for insomnia?
Nitrazepam and temazepam
What are the main side effects of 1st generation (typical) antipsychotics? (5)
EPS
QT prolongation (particularly haloperidol)
Elevated prolactin
Sexual dysfunction
Blood dycrasias
What generation is chlorpromazine?
1st
What generation is amisulpride?
2nd
What generation is pimozine?
1st
What generation is prochlorperizine?
1st
What is the mechanism of action for 1st generation antipsychotics?
Unselective D2 antagonists (hence EPS)
What are the main side effects of 2nd generation antipsychotics? (3)
Weight gain
Postural hypotension (clozapine and quetiapine)
Blood dyscrasias
Which 2nd generation antipsychotics are least likely to cause weight gain?
Aripiprazole, amisulpride, lurisonide
Which antipsychotics are least likely to cause hyperprolactinaemia ?
Quetiapine and Aripiprazole
What is the difference between depot and long acting injections
Depot = oil base
Long-acting = modified to be insoluble and therefore release slowly
Which antipsychotics are available as depot/long-acting injections?
Depot: haloperidol, flupentixol, zuclopenthixol
Long-acting: Aripiprazole, paliperidone, olanzepine, risperidone
What does HDAT mean?
High dose: over 100% of max. BNF dose
When should clozapine be offered?
Treatment failure of 2 antipsychotics (1 has to have been a 2nd generation)
What monitoring is required for clozapine
FBC:
Weekly for 18 weeks
Then twice a week from 18-52 weeks
Then once ever 4 weeks from 52 weeks
What does a red result mean when monitoring clozapine?
STOP and monitor daily until green
What does amber mean when monitoring clozapine?
Monitor twice a week
What are the common side effects with clozapine and how are they treated?
Constipation - laxatives (obvs)
Hypersalivation - antimuscarinic e.g. Hyoscine hydro bromide
Can also reduce seizure threshold - may require prophylactic carbamazepine at high doses
How does smoking affect clozapine levels?
Reduces them via enzyme induction
