Neurology - CBLs/Safe prescribing Flashcards
What factors do you need to take into consideration when deciding which anti-epileptic medication is the most appropriate choice?
Gender
Age – child bearing
Ethnicity – increased risk of steven johns syndrome in Asian, han Chinese, Japanese and thai origine
Type of seizure
Other medication
Co morbidities
Patient preference
What drug treatment options can you use to manage focal temporal lobe epilepsy?
According to NICE Guidelines – levetiracetam or lamotrigine should be offered first-line to people with newly diagnosed focal seizures.
If these are unsuitable or not tolerated:
* Oxcarbazepine, sodium valproate and carbamazepine may be used.
Management of focal temporal lobe epilepsy
If monotherapy with two of the first-line antiepileptic medications is unsuccessful then…
adjunctive treatment may be considered
Options for adjunctive treatment include;
carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate or topiramate.
Sodium valproate must not be used in females of childbearing potential. A recent review of antiepileptic drugs in pregnancy by the MHRA advised that ________ and ________ are safer in pregnancy than the other medications reviewed.
Sodium valproate must not be used in females of childbearing potential. A recent review of antiepileptic drugs in pregnancy by the MHRA advised that **lamotrigine **and levetiracetam are safer in pregnancy than the other medications reviewed.
Which ONE of the following is most likely to interact with the patient’s oral contraceptive to decrease its efficacy
Topiramate
Carbamazepine
Lacosamide
Lamotrigine
Levetiracetam
Carbamazepine
Focal temporal lobe epilepsy
If a decision was made to start lamotrigine, which ONE of the following is the most important information option that should be provided for the patient?
- DVLA guidelines mean that she is able to drive as soon as she has commenced treatment with lamotrigine
- When she starts treatment she may experience some nausea and diarrhoea
- She should see her GP immediately if she experiences a rash
- Myoclonic seizures may be exacerbated by lamotrigine treatment
- She will need to meet the conditions of the Pregnancy Prevention Programme
She should see her GP immediately if she experiences a rash
Patients who have had a first unprovoked seizure or single isolated seizure must not drive for __ __________, driving may then be resumed provided the patient has been assessed by a specialist as fit to drive and investigations do not suggest a risk of further seizures
Patients who have had a first unprovoked seizure or single isolated seizure must not drive for 6 months, driving may then be resumed provided the patient has been assessed by a specialist as fit to drive and investigations do not suggest a risk of further seizures
Can patients with Patients with established epilepsy drive?
. Patients with established epilepsy may drive provided they are not a danger to the public and are compliant with treatment and follow up. They must be seizure-free for at least a year and must not have a history of unprovoked seizures. At the point the patient does not meet this criteria so will be unable to drive.
What is the skin reaction associated with Lamotrigine
Lamotrigine is associated with serious skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis. The highest risk is within the first 8 weeks of treatment and is associated with initial doses being higher than recommended and more rapid dose escalation than recommended.
Which antiepileptic medications require the patient to be kept on the same brand?
What is Category 2 and Category 3
All women and girls on antiepileptic drugs should be offered ____mg of folic acid daily before any possibility of pregnancy. This should be continued until week ____ of pregnancy.
All women and girls on antiepileptic drugs should be offered 5mg of folic acid daily before any possibility of pregnancy. This should be continued until week 12 of pregnancy.
All pregnant females with epilepsy, whether taking medication or not, should be encouraged to notify the…
UK Epilepsy and Pregnancy Register
What advice would you give to a patient on anti-epileptics who wanted to breastfeed?
Women taking antiepileptic monotherapy should generally be encouraged to breastfeed. If they are on combination therapy or there are risk factors such as premature birth, specialist advice should be sought.
All infants should be monitored for sedation, feeding difficulties, adequate weight gain and developmental milestones.
Primidone, phenobarbital and benzodiazepines are associated with an established risk of drowsiness in breast-fed babies and caution is required
Which ONE of the following medications is NOT known to lower the seizure threshold?
A Ciprofloxacin
B Lithium
C Theophylline
D Baclofen
E Gentamicin
Gentamicin
Status Epliepticus
A decision is made to commence intravenous phenytoin. What dose will you prescribe
IV phenytoin loading dose is 20mg/kg followed by maintenance of 100mg every 6-8 hours adjusted according to plasma concentration monitoring. Patient weighs 70kg therefore 70 x 20 = 1400mg
How should the intravenous loading dose of phenytoin be administered? How would you advise the nursing staff to prepare the infusion?
- Manufacturer advises that each injection or infusion should be preceded and followed by an injection of sodium chloride 0.9% through the same needle or catheter to avoid local venous irritation.
- For IV injection – give into a large vein at a rate not exceeding 50mg/minute (a rate of 25mg/minute may be more appropriate in elderly patients and those with heart disease).
- For intravenous infusion – dilute in 50-100mL sodium chloride 0.9% (final concentration should not exceed 10mg/mL) and give into a large vein through an in-line filter (0.22-0.50 micron) at a rate not exceeding 50mg/minute (again a rate of 25mg/minute may be more appropriate in some patients). Complete administration within 1 hour of preparation.
What monitoring is needed whilst intravenous phenytoin is being given?
- You need to monitor the patient’s respiratory rate, blood pressure and pulse.
- Phenytoin can cause hypotension and respiratory depression if it is given too quickly.
- You need continuous ECG monitoring o This is because phenytoin can cause arrhythmia. The injection also contains propylene glycol to help improve its solubility and this is potentially cardiotoxic.
- You also need to monitor phenytoin levels. o These should be taken 24 hours after the loading dose o Target is 10-20 mg/L
The increased dosage of levodopa can result in a phenomenon known as
dopamine dysregulation syndrome,
how does dopamine dysregulation syndrome present
agitation, aggression, hallucinations, and nausea
What are common side effects of levodopa containing medications
Postural Hypotension
Nausea and Vomiting
Dyskinesia – abnormal involuntary movements eg twitching, jerking etc
‘on-off’ effect – fluctuations in effectiveness of the medication
Psychosis/hallucinations
Reddish discolouration of urine upon standing
When starting a patient on levodopa containing medications – what important safety information must be relayed to the patient/carers?
Side Effects: Review common side effects such as nausea, vomiting, dyskinesias, orthostatic hypotension, hallucinations, and mood changes/impluse disorders. Encourage the patient to report any side effects promptly.
Which 2 antiemetics would be NOT suitable to treat the PD patient’s nausea? Why?
Metoclopramide
Cyclizine
Domperidone
Ondansetron
Prochlorperazine
Metoclopramide
Prochlorperazine
Metoclopramide is a dopamine receptor antagonist and may antagonist the effects of levodopa in the treatment of Parkinson’s disease. It can potentially worsen Parkinson’s symptoms and is generally avoided in patients with Parkinson’s disease.
Domperidone- exception- only works peripherally so it doesn’t cross the BBB
How does a patient with adrenal crisis present
The patient’s symptoms of fatigue, weakness, nausea, and dizziness, along with the abnormal laboratory findings (elevated potassium and hyponatremia)
The immediate management of adrenal crisis would involve:
- Administering Intravenous Hydrocortisone: 100mg stat then 60 mg prednisolne PO
- Correcting Electrolyte Imbalances: Addressing the elevated potassium and hyponatremia through appropriate measures.
- Fluid Resuscitation: If the patient is hypotensive or dehydrated, fluid resuscitation may be necessary.
When starting high dose steroids in a patient, what baseline measures should you check?
Calcium vitamin d
Triglycerides
Potassium levels
FRAX score
Vaccination
Chicken pox
Eye Exam
- When starting a patient on steroids, what important counselling points does the patient need to be aware of
Do not stop suddenly
Weight gain is side effect of steroid therapy
Mood changes, anxiety, insomnia, infection gastric upset – side effects
Avoiding infections: as steroids can suppress the immune system. This includes practicing good hand hygiene and avoiding close contact with sick individuals.
Hydration
Medication adherence
Medical alert band
What supportive medications would you expect to see prescribed for a patient on long term steroids?
- Calcium and Vitamin D
- Bisphosphonates: pt increase risk of osteoporosis
- PPI – reduce gastric bleeds.
- Antihypertensives – steroids can contribute to blood pressure.
- Psychiatric medication
- PCP prophylaxis – co trimoxzole 960mg 3 times a week
- What advice would you give when starting a bisphosphonate?
- Medication adherence - Typically, these medications are taken orally, usually on an empty stomach, with a full glass of water, and at least 30 minutes before the first food or drink (other than water) of the day.
- Remain Upright After Taking the Medication prevents irration of the oesophagus
- Avoid taking food or beverages for at least 30 minutes after
- Vitamin D and Calcium
- Dental issues: Osteonecrosis of the jaw associated with the drug.
Which abx is contraindicated in Myasthenia Gravis
Gentamicin
Are you aware of any other medication classes which are to be avoided in patients with MG?
Aminoglycoside Antibiotics:
Fluoroquinolone Antibiotics
Beta-Blockers:
What are the likely causes of decline in conscious level after an assault?
- Expanding haematoma, causing brain compression
- Brain swelling
- Seizure
- Scalp laceration causing major haemorrhage and shock
- Possible intoxication
- Not a primary brain injury - too distant from initial injury
What does the brain require to maintain consciousness?
- Reticular activating formation within the brainstem, and at least one hemisphere are the minimum two anatomical structures required for the patient to be conscious.
- In health, brain tissue requires glucose and oxygenated blood at a cerebral perfusion pressure (“CPP”) of 50 - 60 mmHg
How do you work out CPP
Mean Arterial Pressure (“MAP”) - Intracranial Pressure (“ICP”)
How do you calculate MAP
(2x DBP) + SBP / 3
What is normal range of MAP
70-100
What is normal range of ICP
5-15
In what two way can a head injury affect brain function?
Microscopic level
Macroscopic level
How could a head injury affect brain function at a microscopic level?
At the microscopic level, the trauma leads to direct cellular injury - possibly leading to depolarisation, release of neurotransmitters, or even cell death. The wave of depolarisation spreads and overwhelms normal function and hence consciousness is impaired
How could a head injury affect brain function at a macroscopic level?
Direct Compression to Neurons and Axons:
* The head injury can cause direct compression to neurons (nerve cells) and axons (nerve fibers).
* Compression can impair the function of these neural structures, affecting the transmission of signals.
Brain Displacement and Herniation:
* If the pressure within the skull is very high, the brain can be forced from one anatomical location to another, resulting in herniation.
* Herniation involves marked compression at the site of displacement, causing significant damage.
Secondary Impaired Blood Supply (Perfusion):
* Direct compression to the brain tissue or a global increase in intracranial pressure can lead to secondary impaired blood supply, known as perfusion.
* Munro-Kelli mechanism is mentioned, highlighting how cerebrospinal fluid (CSF) and the venous system initially buffer the mass effect. However, when this buffering capacity is exceeded, there is a decompensation.
* Raised intracranial pressure (ICP) resulting from the head injury can lead to reduced blood supply to the brain.
* Reduced blood supply contributes to a decrease in brain function, leading to a reduction in consciousness.
What is the most commonly used scale to metric for conscious level? How does it work
Glasgow Coma Scale. Three domains - Eyes, Voice and Movement
How do you distinguish between non-epileptic status and convulsive status epilepticus?
NES - Large amplitude
What do you see in the opthalmascope
Papilodeoma- optic disc should be defineced but it is blurred here.
Describe this CT head
- Axial CT of the head which is abnormal
- There is a right sided hyperdensity
- located in the basal ganglia
- This CT has mass effect but no midline shift.
- Calcified Choroid seen in ventricles
CT shows a left-sided frontal acute subdural collection. There is a mass effect (compression of gyri and loss of CSF from sulci) and the is midline shift (evidenced by the septum pellucidum being shifted to the right).
The blood is “acute” as if is hyperdense - so x-rays have been absorbed by the iron in the haem.
It is located in the subdural space as the shape of the collection is a crescent that follows the contours of the brain - cf an extradural (“EDH”), where it is A lens-shaped collection. Also, the history of minimal trauma and anticoagulation lends itself to a subdural location (EDH is usually a young high velocity injury).
