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BNF/Pre-Reg 2017-2018 > NS: General > Flashcards

NS: General Flashcards

1
Q

NSAIDs vary in their selectivitiy for inhibiting different types of cyclo-oxygenase: selective inhibition of what is associated with LESS GI intolerance?

A

They vary in their selectivity for inhibiting different types of cyclo-oxygenase; selective inhibition of cyclo-oxygenase-2 is associated with less gastro-intestinal intolerance.

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2
Q

What are two selective inhibitors of cyclo-oxygenase-2?

A

Etoricixib

Celecoxib

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3
Q

COX-2 selective inhibitors, Diclofenac (what dose daily?) and Ibuprofen (what dose daily?) are associated with an increased risk of thombotic events.

A

Diclofenac: 150mg daily
Ibuprofen 2.4g daily.

Naproxen 1g daily and lower doses of ibuprofen (1.2g daily and less) have not been associated with increased risk of MI.

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4
Q

List the following in terms of decreasing risk of thrombotic events:

Naproxen 1g daily.
Diclofenac 150mg daily.
Ibuprofen 1.2g daily
Ibuprofen 2.4g daily

A

Highest risk are both ibu 2.4g and diclofenac 150mg daily.

Then Naproxen 1g daily: lower thrombotic risk.

Low doses of ibuprofen 1.2g daily or less have not been associated with an increased risk.

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5
Q

Seperate the following into those with the highest, intermediate and lowest risk of serious upper gastro-intestinal risk:

Naproxen
Ibuprofen
indometacin 
Ketoprofen
Piroxicam
Ketoprofen
Diclofenac
Ketorolac
Etorixicib
A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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6
Q

Which of the following is associated with the lowest risk of GI effects?

Naproxen
Ketorolac
Piroxicam
Ketoprofen

A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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7
Q

Which of the following is associated with the highest risk of GI effects?

Ibuprofen - low dose
Ibuprofen - high dose
Etoricoxib
Celecoxib

A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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8
Q

Which of the following has the highest risk of causing serious GI effects?

Indometacin
Piroxicam 
Diclofenac
Naproxen 
Ibuprofen - low dose
A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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9
Q

Serious GI risk of indometacin:

A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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10
Q

Serious GI risk of naproxen:

A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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11
Q

Serious GI risk of piroxicam

A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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12
Q

Serious GI risk of ketorolac

A

Highest risk:
Piroxicam
Ketoprofen
Ketorolac

Intermediate risk:
Indometacin
Diclofenac 
Naproxen
Ibuprofen (high-dose)

Lowest:
Ibuprofen (low-dose)
The selective inhibitors of COX-2 are associated with a lower risk of serious upper GI effects than non-selective NSAIDs.

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13
Q

The use of which of the following should be avoided in the management of pain in sickle-cell disease because of possible accumulation of a neurotoxic metabolite that can precipitate seizures:

Paracetamol
Ibuprofen
Codeine 
Pethidine
Morphine
Diamorphine
A

Pethidine hydrochloride should be avoided if possible because accumulation of a neurotoxic metabolite can precipitate seizures; the relatively short half-life of pethidine hydrochloride necessitates frequent injections.

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14
Q

The use of which of the following is particularly associated with hallucinations and thought disturbances:

Oxycodone
Morphine
Papaveretum
Penazocine
Pethidine
A

Pentazocine has both agonist and antagonist properties and precipitates withdrawal symptoms, including pain in patients dependent on other opioids. By injection it is more potent than dihydrocodeine tartrate or codeine phosphate, but hallucinations and thought disturbances may occur. It is not recommended and, in particular, should be avoided after myocardial infarction as it may increase pulmonary and aortic blood pressure as well as cardiac work.

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15
Q

Anticholinesterases are used 1st line in what type of myasthenia gravis?

A

Anticholinesterases are used as first-line treatment in ocular myasthenia gravis and as an adjunct to immunosuppressant therapy for generalised myasthenia gravis.

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16
Q

Anticholinesterases are used as an adjunct to immunosuppresant therapy in what type of myasthenia gravis?

A

Anticholinesterases are used as first-line treatment in ocular myasthenia gravis and as an adjunct to immunosuppressant therapy for generalised myasthenia gravis.

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17
Q

Anticholinesterases are used as first-line treatment in ocular myasthenia gravis and as an adjunct to immunosuppressant therapy for generalised myasthenia gravis.

Corticosteroids are used when anticholinesterases do not control symptoms completely.
What is frequently used to reduce the dose of corticosteroid?

A

Corticosteroids are used when anticholinesterases do not control symptoms completely. A second-line immunosuppressant such as azathioprine is frequently used to reduce the dose of corticosteroid.

Plasmapheresis or infusion of intravenous immunoglobulin [unlicensed indication] may induce temporary remission in severe relapses, particularly where bulbar or respiratory function is compromised or before thymectomy.

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18
Q

Muscarinic side effects of anticholinesterase inhibitors includes what? (6)

What are these effects reversed by?

A 
Muscarinic side-effects of anticholinesterases include increased sweating, 
increased salivary
and gastric secretions, 
increased gastro-intestinal
 and uterine motility,
 and bradycardia.

These parasympathomimetic effects are antagonised by atropine sulfate.

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19
Q

Myasthenia Gravis: Neostigmine produces a therapeutic effect for up to how long?

A

Neostigmine produces a therapeutic effect for up to 4 hours. Its pronounced muscarinic action is a disadvantage, and simultaneous administration of an antimuscarinic drug such as atropine sulfate or propantheline bromide may be required to prevent colic, excessive salivation, or diarrhoea.

In severe disease neostigmine can be given every 2 hours.

The maximum that most patients can tolerate is 180 mg daily.

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20
Q

Which of the following statements is incorrect?

Neostigmine produces a therapeutic effect for up to 4 hours.

Its pronounced muscarinic action is a disadvantage, and simultaneous administration of an antimuscarinic drug such as atropine sulfate or propantheline bromide may be required to prevent colic, excessive salivation, or diarrhoea.

In severe disease neostigmine can be given every 2 hours.

The maximum that most patients can tolerate is 200 mg daily.

A

The maximum that most patients can tolerate is 180 mg daily.

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21
Q

How does Pyridostigmine compate to neostigmine?

A

Pyridostigmine bromide is less powerful and slower in action than neostigmine but it has a longer duration of action. It is preferable to neostigmine because of its smoother action and the need for less frequent dosage. It is particularly preferred in patients whose muscles are weak on waking. It has a comparatively mild gastrointestinal effect but an antimuscarinic drug may still be required.

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22
Q

Pyridostigmine VS neostigmine:

Which can be used to reverse the actions of the non-depolarising neuromuscular blocking drugs?

A

Pyridostigmine bromide is less powerful and slower in action than neostigmine but it has a longer duration of action. It is preferable to neostigmine because of its smoother action and the need for less frequent dosage. It is particularly preferred in patients whose muscles are weak on waking. It has a comparatively mild gastrointestinal effect but an antimuscarinic drug may still be required.

Neostigmine is also used to reverse the actions of the non-depolarising neuromuscular blocking drugs.

23
Q

Smaller doses of corticosteroid are usually required in what form of myasthenia gravis?

A

In generalised myasthenia gravis prednisolone is given. About 10% of patients experience a transient but very serious worsening of symptoms in the first 2–3 weeks, especially if the corticosteroid is started at a high dose. Smaller doses of corticosteroid are usually required in ocular myasthenia. Once clinical remission has occurred (usually after 2–6 months), the dose of prednisolone should be reduced slowly to the minimum effective dose.

24
Q

What class of drugs are Amifampridine and Fampridine?

A

Acetylcholine-release enhancers.

Amifampridine is licensed for the symptomatic treatment of Lambert-Eaton myasthenic syndrome (LEMS), a rare disorder of neuromuscular transmission.

Fampridine is licensed for the improvement of walking in patients with Multiple sclerosis who have a walking disability.

25
Q

Baclofen, diazepam and tizanidine act principally where?

A

CNS

26
Q

Dantrolene acts where?

A

Peripherally

27
Q

Cannabis extract acts where?

A

Both CNS and peripherally

28
Q

Skeletal muscle relaxants are effective in most forms of spasticity except in what?

A

The rare alpha variety.

29
Q

What is the major disadvantage of treatment with skeletal muscle relaxant drugs?

A

The major disadvantage of treatment with these drugs is that reduction in muscle tone can cause a loss of splinting action of the spastic leg and trunk muscles and sometimes lead to an increase in disability.

30
Q

A cannabis extract is licensed as an adjunct treatment for what?

A

Moderate to severe spasticity associated with MS

31
Q

What is the skeletal muscle relaxant of choice?

A

Dantrolene sodium acts directly on skeletal muscle and produces fewer central adverse effects making it a drug of choice. The dose should be increased slowly.

32
Q

Which of the folllowing is an alpha2-adrenoceptor agonist?

Dantrolene
Diazepam
Cannabis extract
Tizanidine

A

Tizanidine is an alpha2-adrenoceptor agonist indicated for spasticity associated with Multiple sclerosis or spinal cord injury.

33
Q

Can tramadol be used for neuropathic pain?

A

Tramadol hydrochloride can be prescribed when other treatments have been unsuccessful, while the patient is waiting for assessment by a specialist.

34
Q

Carbamazepine taken during the acute stages of trigeminal neuralgia, reduces the frequency and severity of attacks. It is very effective for the severe pain associated with trigeminal neuralgia and (less commonly) glossopharyngeal neuralgia.

What monitoring should take place?

A

FBC and U+Es when high doses of carbamazepine are used.

35
Q

How do non-depolarising neuromuscular blocking drugs work?

A

They compete with acetylchiline for receptor sites at the neuromuscular junction and their action can be reversed with anticholinesterases such as neostigmine.

Aminosteroid group: Pancuroniun (long duration)
Rocuronium (rapid onset, intermediate duration)
Vecuronium (Intermediate duration)

Benzylisoquinolinium: Atracurium (intermediate duration)
Cisatracurium (intermediate but longer than atracurium)
Mivacurium (short duration)

36
Q

Which has a faster onset of action?

Suxamethonium
Non-depolarising drugs

A

Non-depolarising neuromuscular blocking drugs have a slower onset of action than suxamethonium chloride. These drugs can be classified by their duration of action as short-acting (15–30 minutes), intermediate-acting (30–40 minutes), and long-acting (60–120 minutes), although duration of action is dose-dependent.

37
Q

Muscle paralysis is prolonged in individuals deficient in plasma cholinesterase treated with:

Cisatracurium
Pancuronium 
Vecuronium 
Mivacurium 
Rocuronium
A

Mivacurium, a benzylisoquinolinium neuromuscular blocking drug, has a short duration of action. It is metabolised by plasma cholinesterase and muscle paralysis is prolonged in individuals deficient in this enzyme. It is not associated with vagolytic activity or ganglionic blockade although histamine release can occur, particularly with rapid injection.

38
Q

This drug undergoes non-enzymatic metabolism which is independent of liver and kidney function, thus allowing its use in patients with hepatic or renal impairment:

Cisatracurium
Atracurium  
Vecuronium 
Mivacurium 
Rocuronium
A

Atracurium besilate, a mixture of 10 isomers, is a benzylisoquinolinium neuromuscular blocking drug with an intermediate duration of action. It undergoes non-enzymatic metabolism which is independent of liver and kidney function, thus allowing its use in patients with hepatic or renal impairment. Cardiovascular effects are associated with significant histamine release; histamine release can be minimised by administering slowly or in divided doses over at least 1 minute.

39
Q

This drug IS associated with significant histamine release and subsequent cardiovascular effects:

Cisatracurium
Atracurium
Vecuronium
Pancuronium

A

Atracurium besilate, a mixture of 10 isomers, is a benzylisoquinolinium neuromuscular blocking drug with an intermediate duration of action. It undergoes non-enzymatic metabolism which is independent of liver and kidney function, thus allowing its use in patients with hepatic or renal impairment. Cardiovascular effects are associated with significant histamine release; histamine release can be minimised by administering slowly or in divided doses over at least 1 minute.

40
Q

A depolarising neuromuscular blocking drug

A

Suxamethonium

41
Q

Features of the depolarising neuromuscular blocking drug suxamethonium: (4)

A

Features of the depolarising neuromuscular blocking drug suxamethonium:

  1. Most rapid onset of action of any of the neuromuscular blocking drugs.
  2. Action cannot be reversed and recovery is spontaneous.
  3. Anticholinesterases such as neostigmine potentiate the neuromuscular block.
  4. Individuals with myasthenia gravis are resistant to suxamethonium chloride but can develop dual block resulting in delayed recovery.
42
Q

Effect of anticholinesterases on non-depolarising neuromuscular blocking drugs

A

Reverse

43
Q

Effect of anticholinesterases on depolarising neuromuscular blocking drugs

A

Prolong

44
Q

Neostigmine is used specifically for reversal of non-depolarising (competitive) blockade. It acts within one minute of intravenous injection and its effects last for 20 to 30 minutes; a second dose may then be necessary.

What can be given before or with neostigmine to prevent unwanted muscarinic effects?

A

Glycopyrronium bromide or alternatively atropine sulfate, given before or with neostigmine, prevent bradycardia, excessive salivation, and other muscarinic effects of neostigmine.

45
Q

Sugammadex is a used for the rapid reversal of neuromuscular blockade induced by

A

Rocuronium or Vecuronium

46
Q

Haloperidol and levomepromazine are used for the relief of nausea and vomiting when?

A

In terminal illness

47
Q

Separate the following phenothiazine dopamine antagonists used in nausea and vomiting into Sedating and Less sedating:

Prochlorperazine
Chlorpromazine
Perphenazine
Trifluoperazine

A

Less sedating:
Prochloperazine
Perphenazine
Trifluoperazine

Sedating:
Chlorpromazine

48
Q

Aprepitant, fosaprepitant and rolapitant are neurokinin-1 recpetor antagonists and are given with:(2)

A

Dexamethasome and a 5HT3 receptor antagonist.

49
Q

Nabilone is what type of drug with antiemetic properties?

It may be used for nausea and vomiting caused by cytotoxic chemotherapy that is unresponsive to conventional antiemetics,

A

Synthetic cannabinoid

50
Q

On rare occasions if vomiting is severe, short-term treatment with an antihistamine, such as promethazine, may be required. What are two alternatives?

A

On rare occasions if vomiting is severe, short-term treatment with an antihistamine, such as promethazine, may be required. Prochlorperazine or metoclopramide hydrochloride are alternatives.

51
Q

What is the most effective drug for the prevention of motion sickness?

A

Hyoscine hydrobromide.

The sedating antihistamines are slightly less effective against motion sickness, but are generally better tolerated than hyoscine.

Prometh: sedating.
Less sedating: cyclizine, cinnarizine preferred.

52
Q

Which of the following should NOT be stopped before surgery?

Microgynon
Moclobemide 
Levothyroxine
Lithium
Spironolactone
A

Microgynon/COC, stop 4 weeks before.

Moclobemide (MAOi) can have important interactions with some durgs used during surgery, such as pethidine.

Thyroid or antithyroid drugs should normally not be stopped before surgery.

Lithium should be stopped 24 hours before major surgery but the normal dose can be continued for minor surgery (with monitoring).

Potassium-sparing diuretics may need to be withheld on the morning of surgery because hyperkalaemia may develop if renal perfusion is impaired or if there is tissue damage.

53
Q

Which of the following does NOT need to be stopped before surgery?

Ramipril
Azathioprine
Losartan

A

Other drugs that should normally not be stopped before surgery include antiepileptics, antiparkinsonian drugs, antipsychotics, anxiolytics, bronchodilators, cardiovascular drugs (but see potassium-sparing diuretics, angiotensin- converting enzyme inhibitors, and angiotensin-II receptor antagonists), glaucoma drugs, immunosuppressants, drugs of dependence, and thyroid or antithyroid drugs

BNF/Pre-Reg 2017-2018 (144 decks)

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