neuro my notes Flashcards
treatment of dementia:
mild/moderate
severe
non cognitive symptoms?
mild/ mod: NMDA antag
severe memantine
NC: APs (risk of stroke and death) = must assess CV risk
benzos if aggression/ agitation
risk of NMDA antags
galant: SJS
Donepezil: neuroleptic malignant syndrome
rivastigmine: GI disturbances
cholinergic SEs?
DUMBBELS
Avoid Antimuscarinics with what drugs
AP
AD
AH
Urinary spasmodics e.g. solifenicin, tolterodine
severe HS reactions with AEs occur in the first _____ w
8 weeks
which AEs are OD dosing and why
phenobarbital, phenytoin, lamotrigine as long half life
drugs which are barbituates?
phenobarbital
primidone
thiopental
treatment of seizures?
all first line generalized: valproate except absence (ethuxamide)
pre menopausal first line: all generalised first line is lamotrigine (absence is still ethuxamide)
which AEs do you not need to maintain on same brand
gaba
pregab
ethosuxamide
levetiracetam
metoclopramide prokinetic effect does what
increases of absorption of oral analgesia
albumin AEs
phenytoin, carbamazepine, lamo
present in milk?
ZELP
which AEs accumlate in the infant
which decrease sucking reflex
accumlate: phenobarb and lamo
decrease sucking reflex: phenobarb/ prim
HS with which AEs
CPPPL
blood dyscrisis with which AEs?
C VET PLZ
which aes effect eyes
vigabatrin
topirimate (acute myopathy)
which seizures do you not use carba in
atonic tonic myoclonic and absence
which drugs can you not use for the following:atonic tonic myoclonic and absence
carbamazepine
gabapentin
pregabalin
what seizure should you avoid lamo in and why
myoclonic
rashes
which seizures should you avoid phenytoin in?
absence and myoclonic
side efffects phenytoin?
toxicity: SNAtCHeD
change in appearance hypersensitivity SJS hepatotox vitamin D def blood dyscriasis suicidal ideation
phenytoin interactions
Methotrex, trimeth (increased AF effect)
enzyme inhibs/ inducers
anticonvulsant effect antagonism
drugs metabolised by CYP as it is an enzyme inducer
drugs which cause convulsions?
quinolones
tramadol
mefloquine
SSRIs, AP, TCAs
Carbamazepine levels: when do you measure
4-12mg/L
measure after 1-2 weeks
carbamazepine side effects and toxicity
I HANDBAG
hypersensitivity hepatotox blood dyscriasis SJS hyponat= WATER INTOXICATION
carbamazepine interactions?
enzyme inhibs/ inducers
AC effects antagonised
hyponatraemia: aldosterone antagonists, SSRI, TCAs, diuretics, NSAIDs
hepatotox
is an enzyme inducer so anything metabolised by these
valproate side effects
hepatotox
pancreatitis
blood dyscriasis
interactions same as carba
formulation of lorazepam for status epilepticus
when do you give?
when would you repeat?
IV
after 5 minutes
repeat after 10 minutes
what to give if still seizing after 25 minutes of benzo
phenytoin
in community what would you give for seizure?
diazepam rectal or midazolam oral
short acting benzos
CLOT
benzodiazapine OD
flubendazole
withdrawing benzos?
1-2 mg every 2-4 weeks of diazepine at night
500mcg at end
methyphenidate whats it for and whats its class
lisdexamphetamine- used when?
CD Sch 2
first line in adhd
lisdex: if methylphen hasnt worked after 6 weeks- its also CD Sch 2
atomox used when stimulant effects arent tolerated
monitoring with ADHD drugs?
weight/ height of children
tik development
sexual dysfunction
monitor for misuse as study or weight loss drug
switch to non-stimulant
monitor 6 monthly
ADHD drugs increase what levels
dexam, lisdexam, methylpen: na and d
atomox: na
side effects of atomox
hepatotox suicidal ideation QTP na increase= sympathomimetic effects: dry mouth, hyperten, constipation monitor 6m and at dose changes
APs used in bipolar
QORH
Add on li, valproate
withdrawal of antimanic drugs in bipolar?
4 weeks if continuing other drugs
3 months if nothing else
how long to continue therapy after last manic episode in rapid cycling
rapid cycling: 2 years
predisposing to LI tox:
hyponat
but li causes hypernat
side effects with li
TFT, renal imp, benign intracranial hypertension- report headaches and vision changes
QTP and lowers seizure threshold
lithium counselling
report signs of benign intracranial HTN
maintain hydration and salt intake
avoid alc
lithium interactions
EP- AP, Metoclop, PD
decreased renal excretion: ACEI/ARB, NSAIDs
QTP
seizure risk increased
salt balance (alginates)
neurotoxic
SEROTONIN SYNDROME: 5HT ag, SSRI, Granisetron, MAOI, Tramadol
venlafaxine MHRA
Increased risk of post partum haemorrhage
the efficacy between TCAs and SSRIs is the same, what makes SSRIs the preffered choice?
SSRIs safer in OD
TCAs are more: AM, sedating and cardiotoxic
when to r/v MAOIs?
after 2 weeks
TCA cautioned in overdose?
doselupin
examples of TCAs
amitryp
doseulpin OD caution
imipramide (most AM)
lofepramie (hepatotox)
which TCA is the most AM
imipramide
which TCA is safest in OD
Lofepramine
which TCA is hepatotox
lofepramine
MAOIs example
phenelzine- most hepatotox
isocarboxazid- most hepatotox
tranylcypromine- more risk of AH crisis
reversible: moclobenide
review SSRIs how often
how long to wait before deeming ineffective
continue for how long after remission
1-2 weekly at start as can cause suicidal ideation as body decreases s
wait 4 weeks (6w in elderly) before saying its ineffective
6 month (12m in elderly, GAD) 2 years in recurrent
ADs cause what electrolyte imbalance
hyponatraemia- esp SSRI
Serotonin syndrome?
- autonomic dysfunction: libaile BP, hyperthermia, tachy, sweating etc (dysreg between para and sym ns)
- neuromuscular hyperactivity
- altered mental state
MAOI washout
2 weeks except moclobemide
SSRI washout
1 week (2w sertraline, fluox 5w)
TCA washout
1-2 weeks (3 weeks for imipramine or clomipramine)
high risk of withdrawal
paroxetine and velnafaxine as short half lives
max dose citalapram in elderly and hepatic impairment
20mg
normally 40mg
what does TCAs do to BP
hypotension as D blockaid
when is loferamide preferred
less dangerous in OD and has less side effects
but hepatotoxic
how long do MAOIs take to work
3 weeks for a response then continue for another 1-2 weeks for maximum response
which MAOI is most stimulant and can cause hypertensive crisis most
tranylcopromine
which generation are better for negative symptoms of PD
second generation
which APs do you need to monitor concentrations for as per MHRA?
CLOZAPINE, ARIPIRAZOLE, OLANZ, QUETIAPINE, RISP
would you commonly see 2 AP drugs being used at the same time
only in exceptional circumstances e.g. titrating
which AP doesnt increase prolactin levels?
aripirazole as partial agonist
which APs have lowest risk of sexual dysfunction
aripip, quetiapine
which AP has high risk of cardiac side effects
pimozide
QTP is least common with which APs?
aripip, clozapine, flupentixol, risp, sulpride
which generation is more likely to cause postural hypotension
second gernation
which APs cause the least hyperglycaemia?
haloperidol, fluphentixol
what to do if neuroleptic malignant syndrome occurs with APs?
hold for 5 days
FIRST GENERATION APs 4 categories:
- phenothiazines: e.g chlorpromazine
- butyrophenones: haloperidol- most EPS
- thioxantheses: -pentixol
- others e.g. pimozine, sulpiride
which APs are hepatotoxic
phenothiazines
which generation causes EPS and which causes metabolic SEs
1st: EPS
2nd: metabolic
when would you rx clozapine
resistant schizo when tried more than 2 drugs including 2nd gen for 6-8 weeks
when would you retitrate clozapine
two or more missed doses
clozapine side effects
MAG: myocarditis- STOP if tachy in first 2 m
Agranulocytosis: FBC every 8 weeks then 2 weekly for a year then monthly
GI obstruction- do NOT give constipating meds
which APs have the highest risk of EP symptoms
group 1 phenothiazines and haloperidol
how could you treat EPS
antimuscarinics
which generation has highest risk of hyperprolactinaemia
first generation
hyperglycaemia most common with which APs?
CiROQ
treating neuroleptic malignant syndrome caused by APs?
bromocriptine/ dantrolene- dopamine receptor agonist
APs monitor?
FBC
LFT
Electrolytes
lipids- 3m then yearly
ergot dopamine agonists examples
bromocrip
cabergoline
pergolide
non ergot agonists?
pramipex
ropinirole
rotigotine
MAOBs for PD?
Selegeline, rasageline
what does amantadine and apomorphine treat
PD- weak DRA
COMT Inhibitor examples
entacapone (colours urine), tolcapone (hepatotox)
apomorphine for PD side effects- how to overcome this?
nausea and vomiting give with domperidone prophylaxis 2 days before
CAUTION of using domperidone 2 days before apopmorphine to decrease nausea and vomiting?
both cause QTP- risk benefit
what would you use to treat advanced PD
Apomorphinee SC/ IV
what to give to treat the non cognitive symptoms of PD:
- day time sleepiness
- postural hypotension
- psychotic symptoms
- REM
- Salivation
- modafanil
- midodrine or fludrocortisone
- dont treat unless not tolerated- quetiapine
- clonazepam or melatonin
- glycopyronium or botox
what do you use to treat PDD
Rivastigmine
treatment of PD?
+ affecting QOL: levodopa
- affecting QOL: any choice but ldopa best
ergot derived DRAs side effects?
impulse conrol disorders
sleepiness and onset of sleep
psychotic symptoms
hypotension
counselling with MAOIBs for PD
driving as metabolised to amphetamine
Do not purchase any sympathomimetics OTC= hypertensive crisis.
e.g. nasal decongestants: pseudoeph, phenylephedrine, zylometazoline
when are COMT inhibitors used? examples of these?
entacapone, tolcapone
used for end dose flucutations
counselling with COMT inhibitors?
entacapone: red urine
tolcapone: hepatotox