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Q&A Flashcards

1
Q

Which drugs can increase cognitive impairment in dementia

A

antimuscarinic drugs- increase cognitive impairment
e.g. antidepressants/ antihistamines/ antipsychotic/ urinary spasmodics

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2
Q

which drugs are 1st line in mild- moderate Alzheimers disease

A

Acetylcholinesterase inhibitors as monotherapy
donepezil/ galantamine/ rivastigmine

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3
Q

what is first choice in severe Alzheimers (and second line in mild-moderate)

A

memantine

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4
Q

In which types of dementia are acetylcholinesterase inhibitors not used

A

Vascular dementia/ frontotemporal dementia

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5
Q

why should antipsychotics not be used in dementia if possible

A

increased risk of stroke, increased risk of death

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6
Q

when can antipsychotic use in dementia be justified

A

if patient is at risk of harming self or others or agitation/ halucinations/ delusions are very distressing

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7
Q

how often should antipsychotics be reviewed in dementia

A

every 6 weeks

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8
Q

What are the STOPP criteria for acetylcholinesterase inhibitors

A

known history of bradycardia, heart block, recurrant unexplained syncope, concurrent use of drugs that promote bradycardia

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9
Q

Galantamine in renal impairment

A

avoid if eGFR is less than 9

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10
Q

what should you warn patients about with galantamine

A

look out for symptoms of severe cutaneous reactions

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11
Q

why are rivastigmine patches used

A

Less likely to cause side effects

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12
Q

How to apply and remove rivastigmine patches

A

Remove patch after 24 hours, avoid same area for 14 days

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13
Q

what should be monitored with rivastigmine

A

body weight- can cause weight loss via appetite supression

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14
Q

rivastigmine with prolonged diarrhoea or vomitting (dehydration)

A

withhold until resolution then reiterate if needed

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15
Q

which patients can use memantine with caution

A

epileptic

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16
Q

what class of drugs in memantine

A

glutamate receptor antagonist

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17
Q

in which impaired states should memantine be avoided

A

severe hepatic impairment
renal impairment if eGFR is <5

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18
Q

which anti epileptics can be taken once a day at bedtime

A

lamotrigine, perampanel, phenobarbital, phenytoin

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19
Q

which anti epileptics should be prescribed by brand

A

carbamazepine, phenobarbital, phenytoin, primidone

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20
Q

which anti epileptics do not have to be prescribed by brand

A

brivaracetam, ethosuximide, gabapentin, pregabalin, lacosamide, levetiracetam, tiagabine, vigabatrin

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21
Q

what are the symptoms of anti epileptic hypersensitivity syndrome

A

fever, rash, lymphadenopathy
1-8 weeks since starting
withdraw immediately, do not re-expose

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22
Q

How do you stop/ switch anti epileptics

A

Gradually as can precipitate rebound seizure if too sudden
One at a time

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23
Q

How long from an isolated epileptic seizure til you can drive again if you are seizure free

A

6 months, then assessed by specialist as ‘fit to drive’ with no further risk

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24
Q

Can patients with established epilepsy drive

A

Provided they are not a danger to the public, and are compliant with treatment and follow up
seizure free for at least 1 year with no history of unprovoked seizure

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25
Q

Can patients drive if they have seizures while they are asleep?

A

Not permitted to drive from 1 year since date of seizure UNLESS
- only ever had seizures while asleep over the course of at least 1 year
- only had seizures while asleep for 3 years if they used to have seizures while awake

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26
Q

Can you drive if you have epilepsy and are trying out a different medicine?

A

No, you cannot drive for 6 months after last dose of old medication

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27
Q

Which are the safer anti epileptics for pregnant ladies

A

Lamotrigine or levotiracetam (mono therapy at lowest effective dose)

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28
Q

Important interaction to consider about antiepiletics and young women

A

OHC and anti epileptics interact to reduce both of their efficacy
Many anti epileptics are teratogenic

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29
Q

What can be given to pregnant epileptic women to reduce the risk of neural tube defects

A

Folic acid

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30
Q

How can we reduce the risk of neonatal haemorrhage when a baby is born to an epileptic mother

A

Vitamin K injection at birth

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31
Q

Which anti epileptics can cause withdrawal in baby

A

benzodiazepines and phenobarbital

32
Q

what should we monitor in breast fed babies born to epileptic others

A

sedation, feeding difficulties, adequate weight gain, developmental milestones
serum drug concentration

33
Q

What are the drugs of choice in focal seizures

A

Carbemazepine / lamotrigine

34
Q

What are the drugs of choice in tonic clonic seizures

A

sodium valproate/ lamotrigine

35
Q

what are the drugs of choice in absence seizures

A

ethosuximide/ sodium valproate

36
Q

what is the drug of choice in myoclonic seizures

A

sodiu valproate/ topiramate/ levetiracetam

37
Q

which types of seizures is carbamazepine (and oxcarbemazepine), pregabalin and gabapentin going to exacerbate

A

tonic, atonic, myoclonic, absence

38
Q

lamotrigine exacerbates which seizure type

A

myoclonic

39
Q

phenytoin exacerbates which seizure types

A

absence, myoclonic

40
Q

what should be given instead of IV phenytoin

A

IV fosphenytoin

41
Q

what should you give if seizure lasts longer than 5 mins and you have IV access

A

IV lorazepam- repeat once after 10 mins if still going
Monitor for respiratory depression and hypotension

42
Q

what should you give if seizure lasts longer than 5 mins and no IV access

A

diazepam rectal solution/ midazolam solution to buccal cavity

43
Q

if seizure lasts longer than 25 mins

A

Contact ICU, you need fosphenytoin/ phenytoin/ phenobarbital

44
Q

if seizure lasts longer than 45 mins

A

anaesthesia- thiopental/ midozolam/ propofol

45
Q

Which supplement should you consider with carbemazepine, phenytoin, valproate, phenobarbital

A

consider vitamin D supplementation if immobilised/ inadequate exposure to sun or dietary calcium

46
Q

which individuals have a higher risk of Steven Johnsons syndrome with carbamazepine/ phenytoin

A

Han chineese/ thai origin with HLA-B*1502 allele

47
Q

what is the therapeutic range of carbamazepine

A

4-12 mg/L after one- two weeks

48
Q

what should patients be vigilant for with carbamazepine

A

blood, liver, skin disorders
seek attention if fever, rash, mouth ulcers, bruising, bleeding

49
Q

what should patients be vigilant for with ethosuximide/ phenytoin

A

blood disorders- fever, mouth ulcers, bruising, bleeding
check FBC

50
Q

Which brand of gabapentin may cause high levels of excipients in low body weight patients

A

Rosemont brand solution
high levels of propylene glycol, acesulfame K and saccharin sodium at high doses

51
Q

Which patients may need to reduce their dose of gabapentin/ pregabalin due to risk of respiratory depression

A

compromised respiratory function; respiratory and neurological disease; renal impairment; use with other CNS depressants; elderly people

52
Q

which schedule/ drug class is gabapentin/ pregabalin

A

3, class C

53
Q

lifestyle advice for gabapentin/ pregabalin

A

drinking with this medication can be fatal

54
Q

Signs of SJS with lamotrigine

A

first 8 weeks usually get a rash- could be hypersensitivity especially used alongside valproate

55
Q

If you use lamotrigine in pregnancy

A

check plasma levels before, during and after pregnancy as plasma levels change

56
Q

patients taking lamotrigine need to be alert to

A

signs of bone marrow failure- anaemia, bruising, infection

57
Q

which conditions are worsened by lamotrigine

A

brugada syndrome, myoclonic seizure, parkinson’s disease

58
Q

How does levetiracetam affect ability to drive

A

increases sleepiness and other CNS effects

59
Q

when would you need to talk to the doctor with levetiracetam

A

signs of depression/ suicide ideation
worsening of seizure

60
Q

when do you need to adjust dose of levetiracetam in terms of impairment

A

if severe hep impairment if CrCl is less than 60 (half maintenance dose)
if eGFR is less than 80

61
Q

what does phenytoin toxicity look like?

A

slurred speech, hyperglycaemia, confusion, eye movement, double vision, poor muscle control

62
Q

what might happen if phenytoin is injected too fast?

A

atrial/ ventricular conduction depression, ventricular fibrillation, respiratory arrest, tonic seizure, bradycardia and hypotension

63
Q

what is the target level of phenytoin for 3 months of age +

A

10-20mg/L unbound

64
Q

what are the max daily doses of pregabalin in renal impairment

A

30-60= 300mg
15-30= 150mg
less than 15= 75mg

65
Q

important side effects to look out for with valproate include

A

hepatic dysfunction- withdraw immediately if persistent vomitting, abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness, loss of seizure control. Check hepatic function in first 6 months
pancreatitis

66
Q

how to withdraw valproate

A

slowly, over at least 4 weeks

67
Q

why do you need to stay hydrated with topiramate

A

risk of kidney stones and metabolic acidosis

68
Q

topiramate- dose adjustment in impairment

A

half usual dose if creatinine clearance is less than 70

69
Q

topiramate ocular effects

A

if raised intraoccqular pressure- discontinue and refer to ophthalmology

70
Q

zonisamide is linked to hypersensitivity with

A

other anti epileptics and sulphonamides

71
Q

how long should breast feeding be avoided after last dose of zonisamide

A

4 weeks

72
Q

how long should effective contraception be used after last dose of zonisamide

A

1 month

73
Q

zonisamide with impairment

A

slowly increase dose at 2 week intervals

74
Q

target plasma conc of phenobarbital

A

15-40mg/L- but tolerance can occur

75
Q

what is the antidote to midazolam

A

flumazenil

76
Q
A

nervous system (3 decks)

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