BNF Chapter 4: CNS Flashcards
(235 cards)
1
Q
What medication is an example of a hypnotic, and what is it prescribed for?
A
Zopiclone, prescribed for severe insomnia where all non-drug measures have failed and the insomnia is severe and disabling.
2
Q
What is the maximum length of time it is recommended that hypnotics are prescribed for?
A
Up to 2 weeks only
3
Q
Melatonin 2mg MR and Adalfex tablets are hypnotics, but have specific licensing and are not recommended in certain patient groups.
A
.
4
Q
What are the two examples of anxiolytic drugs?
A
Diazepam
Chlordiazepoxide
5
Q
When is the only time chlordiazepoxide is licensed?
A
For alcohol withdrawal, under specialised services
6
Q
When are benzodiazepines indicated for use in anxiety?
A
Short-term relief (2-4 weeks) when the anxiety is severe and disabling
7
Q
Benzodiazepines and _ should not be used in combination, as there is a risk of potentially fatal respiratory depression.
A
Opioids
8
Q
Benzodiazepines should not be used to treat generalised anxiety disorder, unless it is short-term for a crisis.
A
.
9
Q
What are some examples of first-generation antipsychotics?
A
Chlorpromazine
Flupentixol
Haloperidol
Sulpiride
Trifluoperazine
Zuclopenthixol
10
Q
What are some examples of second-generation antipsychotics?
A
Amisulpride
Aripiprazole
Olanzapine
Quetiapine
Risperidone
11
Q
Haloperidol poses risks in elderly patients, for the treatment of delirium. When should it be considered?
A
When non-pharmacological interventions are ineffective, and no contraindications are present (Parkinson’s disease and dementia with lewy bodies).
12
Q
What tests should be done prior to intiating haloperidol treatment?
A
Baseline ECG and correction of any electrolyte disturbances ; cardiac and electrolyte monitoring should be repeated during treatment.
13
Q
What potential side-effects of haloperidol should be investigated ASAP?
A
Extrapyramidal adverse effects, such as acute dystonia, parkinsonism, tardive dyskinesia, akathisia, hypersalivation and dysphagia.
14
Q
Quetiapine MR is more expensive than standard formulations.
True or False?
A
True
15
Q
Clozapine is a drug that can be very harmful. What are some potentially fatal risks of the drug?
A
Intestinal obstruction, faecal impaction and paralytic ileus. Constipation should be reported immediately.
16
Q
What are some examples of antimanic drugs?
A
Carbamazepine
Sodium valproate
Lithium
17
Q
Lithium should be prescribed by brand name. True or False?
A
True
18
Q
Lithium patients should have a purple book.
A
19
Q
What are the limitations on prescribing sodium valproate?
A
Shouldn’t be used to treat migraine and bipolar during pregnancy, or treating epilepsy during pregnancy unless there are no other effective treatments available. Valproate-containing medicines should also not be given to any female that is able to have children unless the conditions of a new pregnancy prevention programme are met.
20
Q
Pregnancy Prevention Programme
Valproate-containing medicines must not be used in any
woman or girl able to have children unless the conditions of a new pregnancy prevention
programme are met. These include:
- an assessment of each patient’s potential for becoming pregnant
- pregnancy tests before starting and during treatment as needed
- counselling about the risks of valproate treatment and the need for effective contraception
throughout treatment - a review of ongoing treatment by a specialist at least annually
- introduction of a new risk acknowledgement form that patients and prescribers will go through
at each such annual review to confirm that appropriate advice has been given and understood.
A
..
21
Q
What risks does valproate exposure in utero pose?
A
High risk of developmental disorders and congenital malformations.
22
Q
What are some examples of TCAs?
A
Amitriptyline
Nortriptyline
Lofepramine
Trazodone
23
Q
What is amitriptyline primarily used for?
A
Neuropathic pain
24
Q
When is pregabalin classed as ‘green’ for treating generalised anxiety disorder?
A
When initiated by a specialist, after SSRIs or venlafaxine have been ineffective, poorly tolerated or are clinically inappropriate.
25
Which groups of patients may have a higher risk of repiratory depression whilst using pregabalin?
-Patients with compromised respiratory function
-Patients with repiratory or neurological disease
-Patients with renal impairment
-Patients using opioids/other CNS depressants
-People over 65
26
Pregabalin is safe in pregnancy.
True or False?
False
It slightly increases the risk of major congenital malformations; should be avoided in pregnancy unless clearly necessary.
27
Why are amitriptyline and imipramine preferred as depression treatments over nortriptyline?
They are more cost-effective.
28
Why is Dosulepin classified as 'Do Not Prescribe' for new patients?
Extremely dangerous in overdose, and not recommended for depression.
29
Moclobemide 150mg and 300mg are monoamine-oxidase inhibitors- it poses little dietary restrictions and few interactions
.
30
What are some examples of SSRIs?
Citalopram
Fluoxetine
Sertraline
Vortioxetine
31
The SSRI that is first-line depends on the patient that it is for!!
32
Which SSRI would be first-line for a breast-feeding patient?
Sertraline
33
SSRI's and Upper GI Bleeds
- SSRIs can increase upper GI bleed risk, especially when used alongside _
- If a patient is particularly high risk of an upper GI bleed then a gastro-protective agent could be considered.
NSAIDs
34
What is the maximum daily dose of citalopram in adults? What about in the elderly (Over 65) and those with reduced hepatic function?
Adults- 40mg
Elderly and reduced hepatic function- 20mg
35
When would citalopram use be completely contraindicated?
In patients with known QT interval prolongation or congenital long QT syndrome, or if the patient is using other medicines that are known to prolong QT interval
36
When would citalopram use be cautioned?
In patient at higher risk of developing Torsade de Pointes, including those with congestive heart failure, recent MI, bradyarrhythmias, or a predisposition to hypokalaemia or hypomagnesaemia due to illness or drug therapy.
37
How should the dose of citalopram oral drops be stated?
Stated in drops, not ml.
38
Fluoxetine can be used in children and adolescents. CAHMS will initate treatment and then the prescribing will be handed over to primary care. Fluoxetine 20mg dispersible tablets are cost-effective if the patient has swallowing difficulties. Sertraline is second-line after consultant/specialist initiation.
.
39
Vortioxetine is licensed for treating major depressive episodes.
40
SSRIs and SNRIs (venlafaxine) can increase _ risk; some data suggests that the use of these antidepressants in the last month before birth can increase the risk of postpartum haemorrhage. Consider risk vs benefit.
Bleeding
41
Other antidepressant drugs include mirtazapine, duloxetine and venlafaxine.
42
In what patient groups should venlafaxine be avoided?
Patients with pre-existing heart disease and anyone with uncontrolled or untreated hypertension. Review BP after initiation, dose increase and annually; if raised then only continue venlafaxine if BP under control and alternative antidepressant is unsuitable.
43
What is CNS stimulant drug example and what is it used for?
Modafinil 100mg and 200mg tablets- narcolepsy and narcolepsy secondary to parkinsons disease.
44
What are some examples of drugs that can be used to treat ADHD?
Methylphenidate
Lisdexamfetamine
Dexamfetamine
Atomoxetine
Guanfacine
45
Why should methylphenidate be prescribed by brand name, and should be cautioned if switching patients between different long-acting formulations of the drug?
Different formulations have different dosing frequencies, food instructions, amounts and timing. Specific dosing recommendations for each formulation should be followed.
46
What drug can be used in the treatment of obesity?
Orlistat 120mg capsules
47
What drugs can be used to treat nausea and vertigo?
Metoclopramide
Domperidone
Cyclizine
Prochlorperazine
Cinnarizine
Betahistine
48
Metoclopramide
* For adults, the maximum dose in 24 hours is _mg (or 0.5mg per kg bodyweight). The usual dose
is 10mg three times a day and should only be prescribed for short-term use (up to 5 days)
* Off label use of metoclopramide is recognised as standard practice in palliative medicine. JAPC
recognises that long term use of metoclopramide may be appropriate in some patients given
orally/parentally
* Use in patients under 20 years of age is restricted and likely to cause dystonic reactions
30
49
What is the maximum metoclopramide dose in 24h for an adult?
30mg (or 0.5mg per kg of bodyweight). 10mg TDS is the usual dose, and should only be used for up to five days
50
Domperidone
Domperidone may be associated with a small increased risk of serious ventricular arrhythmia or
sudden cardiac death. These risks may be higher in patients older than 60 years and in patients
who receive daily oral doses of more than 30 mg.
* For adults the maximum dose in 24 hours is 30mg. The duration of treatment should not
usually exceed one week.
* Domperidone is preferred in patients where the risk of dystonic reactions is high i.e., young
women, children, the elderly, and those with Parkinson’s disease.
..
51
Why is domperidone no longer licensed for children under 12?
Lack of efficacy
52
What specifically is prochlorperazine used for and in what patient group should it be avoided and why?
Vertigo. Should be avoided in the elderly if possible due to extrapyramidal side-effects
53
Haloperidol is recommended to control opiate induced vomiting. What dose should be used?
1.5mg orally once or twice daily , or 2.5mg IM to stop active vomiting.
54
Nausea and Vomiting in Pregnancy
* Reassure women that mild to moderate nausea and vomiting are common in pregnancy and likely
to resolve before 16-20 weeks.
* For pregnant women with mild-to-moderate nausea and vomiting who prefer a non-pharmacological option, suggest that they try ginger.
* When considering pharmacological treatments for nausea and vomiting in pregnancy, discuss the
advantages and disadvantages of different antiemetics with the woman. Take into account her
preferences and her experience with treatments in previous pregnancies.
* For pregnant women with nausea and vomiting who choose a pharmacological treatment, offer an
antiemetic.
.
55
Paracetamol is the simple analgesic of choice; co-codamol and co-dydramol are listed by the BNF as being less suitable.
.
56
Why should effervescent analgesics be avoided unless someone has genuine swallowing difficulties?
They have a high sodium content and are associated with significantly increased odds of adverse cardiovascular events compared with standard formulations (does not apply to dispersible aspirin)
57
What patient groups may be at an increased risk of experiencing analgesic toxicity at therapeutic doses?
Patients with a bodyweight under 50kg
Patients with risk factors for hepatotoxicity, such as alcoholics, malnourishment, chronic dehydration, frailty etc)
Use clinical judgement:
- Patient with risk factors: consider reducing total daily dose of paracetamol to max 3g in 24h
-Patient under 50kg: consider reducing dose using 15mg/kg (max 60mg/kg) and a max of 2g in 24 hours.
58
Opioid Analgesics: Benzodiazepines and Opioids
Risk of potentially fatal respiratory
depression. Only prescribe together if there is no alternative and closely monitor patients for signs of
respiratory depression.
At the end of treatment, taper dosage slowly to reduce the risk of withdrawal effects. Consider the possibility of hyperalgesia if a patient on long-term opioid therapy presents with increased sensitivity to pain.
Long-term (>3months) use in non-cancer pain, even at therapeutic doses, carries an increased risk of dependence and addiction. Before prescribing opioids, discuss with the patient the risks and features of tolerance, dependence, and addiction, and agree together a treatment strategy and plan for end of treatment.
.
59
What are some examples of 'weak' opioid analgesics?
Codeine phosphate
Dihydrocodeine
Tramadol
60
Codeine should only be used to relieve acute moderate pain, if it cannot be relieved by other painkillers such as paracetamol and ibuprofen. How old must the patient be?
12 years plus
61
Tramadol
-Consider for neuropathic pain only if acute rescue therapy is needed, as long-term use is not advised
-Has a high incidence of ADRs and drug interactions
-Schedule _ CD- Rx is only valid for 28 days and for 30 days treatment (30 days unless exceptional circumstances)
3
62
For Schedule 2, 3 and 4 CD's, what is the maximum prescription validity length and how long of a supply should be prescribed as a maximum (except in excepional circumstances)?
28 days validity, and no longer than 30 days course length in one go
63
What are some examples of 'strong' opioids?
Morphine sulphate
Oxycodone
Fentanyl
Buprenorphine
64
Morphine sulphate is first-line for the prescribing of strong opioids. What are the different formulations?
-Modified-release capsules, such as Zomorph
-Immediate release tablets, such as Sevredol
-Oral solution 10mg/5ml
-Injection Ampoules 10mg/ml
65
Oxycodone or Fentanyl are the second-line options for strong opioid prescribing. What formulation options are there?
Oxycodone:
-Modified release tablets
-Immediate release capsules
-Oral solution 5mg/5ml
Fentanyl:
-Patch
66
Whilst a patient is on regular morphine, what else should they be prescribed?
A laxative
An anti-emetic if appropriate
67
Fentanyl
Always fully inform patients and their caregivers about directions for safe use for fentanyl patches,
including the importance of:
* not exceeding the prescribed dose
* following the correct frequency of patch application, avoiding touching the adhesive side of
patches, and washing hands after application
* not cutting patches and avoiding exposure of patches to heat including via hot water (bath,
shower)
* ensuring old patches are removed before applying a new one
* following instructions for safe storage and properly disposing of used patches or those which
are not needed.
Remind patients (or caregivers) to:
.
* Follow the correct frequency of patch application, avoiding touching the adhesive side of patches,
and washing hands after application. Remove old patches before applying a new one.
* Avoiding exposure of patches to heat including via hot water (bath, shower)
* Follow instructions for safe storage and properly disposing of used patches or those which are not
needed. After use, patches should be folded so that the adhesive side of the patch adheres to itself
and then placed back into the original sachet.
* Be aware of the signs and symptoms of fentanyl overdose (e.g., difficulty/ shallow breathing;
tiredness; extreme sleepiness/ sedation; feeling faint, dizzy or confused) and seek medic
.
68
What are some signs of fentanyl overdose?
Difficulty /shallow breathing, tiredness, sedation, feeling faint, dizziness and confusion.
69
When is the only time fentanyl patches should be considered for a patient?
When the patient is on a stable dose of opioid but they are unable to swallow/comply with oral medication.
70
Buprenorphine
1. Buprenorphine patches are classified as GREY - the patches should be prescribed by brand as the
frequency to be applied may vary between brands
2. Buprenorphine patches at lower doses are broadly as effective as codeine or tramadol but much more
expensive.
3. The patches are unsuitable in acute or unstable pain due to the need for slow titration of doses; it may
take up to 72 hours to achieve a stable blood level after a change in dose.
4. The preferred cost-effective brand for low dose (7 day) patch is Reletrans
5. Higher strength patches are also available, but the bioavailability and application varies between
brands. Different brands are not interchangeable. Check individual SPC carefully.
6. The preferred cost-effective high strength brand (replace after 96 hours) is Relevtec
.
71
Why is buprenorphine not suitable for acute pain?
It can take up to 72 hours to achieve a stable blood level after a change uin dose- does not provide quick relief
72
What are some drugs that can be used to treat migraines?
Aspirin
Ibuprofen
Paracetamol
Sumatriptan
Zolmitriptan
Prochlorperazine (if N&V)
Metoclopramide (N&V)
73
Triptans:
Should not be taken by people who have: Uncontrolled or severe hypertension; Cardiovascular disease, or are at high risk of cardiovascular disease; Coronary vasospasm (including Prinzmetal's angina).
* For all triptans there is good evidence that a second dose is effective for relapse but very little to
show that it is the most appropriate treatment.
* All triptans except intranasal sumatriptan are unlicensed for use in children under 18. 5HT1
receptor agonists for children (aged 12-17) should be referred and initiated by a specialist.
Sumatriptan and zolmitriptan oral formulations are treatment options (see BNF for children).
* Where triptans are indicated for acute migraine NICE CG150 recommends the use of combination
therapy with a triptan and an NSAID, or a triptan and paracetamol, for first-line treatment of acute
migraine with or without aura.
* if vomiting restricts oral treatment, consider a non-oral formulation (such as sumatriptan nasal
spray or subcutaneous sumatriptan.
.
74
What does NICE recommend for the first-line treatment of acute migraine with or without aura?
A triptan (sumatriptan or zolmitriptan) with an NSAID or paracetamol
75
What medications can be used for the prophylaxis of migraines?
Propranolol 80-160mg daily (first-line)
Topiramate 50-100mg daily (second-line)
Amitriptyline 25-150mg daily (second-line)
76
Migraine Prophylaxis
- Consider prophylaxis if migraine is disabling and reducing quality of life, e.g., frequent attacks (>1 per
week on average) or prolonged severe attacks. Start at low dose and gradually increase according to
efficacy and tolerability.
- If the patient responds well to prophylactic treatment a trial of gradual drug withdrawal should be
considered after six months to one year.
- Good response is a 50% reduction in severity and frequency of attacks; treatment failure is a lack of
response to the highest tolerated dose used for 3 months.
- Candesartan (16 mg daily) can be considered as a prophylactic treatment for patients with
episodic or chronic migraine.
-Metoprolol at a dose of 100mg-200mg daily in divided doses is a suitable licensed alternative if
propranolol cannot be tolerated; Nortriptyline is 2nd line option (less cost effective) only to be used if
amitriptyline is effective but patient unable to tolerate side effects.
- Verapamil may be considered for prophylactic treatment during a bout of cluster headache. If
unfamiliar with its use for cluster headache, seek specialist advice before starting verapamil, including
advice on electrocardiogram monitoring.
.
77
What is considered a good response to migraine prophylaxis treatment?
Good response is a 50% reduction in severity and frequency of attacks; treatment failure is a lack of
response to the highest tolerated dose used for 3 months.
78
Topiramate as Migraine Prophylaxis
-Advise women and girls of childbearing potential that topiramate is associated with a risk of foetal
malformations and can impair the effectiveness of hormonal contraceptives.
-Pregnancy testing should be performed before initiating, and a highly effective contraceptivemethod advised.
- EMA March 2018 recommends a ban on the use of valproate-containing medicines for migraine or
bipolar disorder during pregnancy, and a ban on treating epilepsy during pregnancy unless there is no
other effective treatment available. Valproate-containing medicines must not be used in any woman or girl able to have children unless the conditions of a new pregnancy prevention programme are met.
79
What is first-line for migraine prophylaxis?
Propranolol
80
What are some examples of antiepileptic medications?
Clonazepam
Carbamazepine
Ethosuximide
Gabapentin
Lacosamide
Lamotrigine
Levetiracetam
Oxcarbazepine
Phenobarbital and other barbiturates
Phenytoin
Pregabalin
Sodium valproate
Topiramate
Zonisamide
81
What are the three risk-based categories that antiepileptics are divided into?
Category 1: prescribers are advised that patients receiving treatment for epilepsy are maintained
on the same manufacturer.
Category 2: continuity of manufacturer is based on clinical judgement taking into account factors such as seizure frequency and treatment history
Category 3: it is usually unnecessary to ensure a specific manufacturer
82
What anti-epileptics fall into category 1 of risk-based categories?
carbamazepine
phenytoin
phenobarbital
primidone
83
What antiepileptics fall into category 2 of the risk-based categories?
clobazam
clonazepam
eslicarbazepine
lamotrigine
oxcarbazepine
perampanel
retigabine
rufinamide
topiramate
valproate
zonisamide
84
What antiepileptics fall into category 3 of the risk-based categories?
ethosuximide
gabapentin
lacosamide
levetiracetam
pregabalin
tiagabine
vigabatrin
85
Antiepileptic Drugs in Pregnancy
- Lamotrigine and Levetiracetam are the safer of the antiepileptic medicines in pregnancy.
* Women using antiepileptic drugs who are planning to become pregnant should be offered folic acid
5mg daily before any possibility of pregnancy.
* Urgently refer women who are planning to become pregnant for specialist advice on their
antiepileptic treatment.
* These are usually initiated by specialist. GPs using antiepileptic drugs for other indications must
carefully consider the risk and benefit.
-There is an increased risk of teratogenicity associated with the use of antiseizure medications
(reduced if treatment is limited to a single drug). Ensure adequate contraception. Those who wish to
become pregnant or become pregnant should be referred to an appropriate specialist for advice.
-Be aware that long-term treatment with some antiseizure medications (such as carbamazepine,
phenytoin, primidone and sodium valproate) is associated with decreased bone mineral density and
increased risk of osteomalacia.
-Be aware that oestrogen-containing hormonal contraceptives and hormone replacement therapy can
impair the effectiveness of lamotrigine.
.
86
What are the safest antiepileptics to be used during pregnancy?
Lamotrigine and Levetiracetam
87
Which antiepileptic medications are associated with decreased bone mineral density and osteomalacia when used long-term?
Carbamazepine
Phenytoin
Primidone
Sodium valproate
88
Before a woman of childbearing potential can be initiated on valproate, the conditions of a new pregnancy programme must be met. What are these conditions?
-an assessment of each patient’s potential for becoming pregnant
- pregnancy tests before starting and during treatment as needed
- counselling about the risks of valproate treatment and the need for effective contraception
throughout treatment
- a review of ongoing treatment by a specialist at least annually
- introduction of a new risk acknowledgement form that patients and prescribers will go through
at each such annual review to confirm that appropriate advice has been given and understood.
89
Children exposed to valproate in utero are at high risk of what?
Developmental disorders and congenital malformations
90
Why should topiramate tablets be prescribed rather than capsules?
Capsules are more expensive
91
What are the risks associated with topiramate in pregnancy?
Foetal malformations and can impair the effectiveness of hormonal contraceptions
92
What is Midazolam used for?
The management of convulsive seizures in the community
93
Midazolam Buccal (Buccolam)- pre-filled syringe 2.5mg/0.5ml, 5mg/1ml, 7.5mg/1.5ml, 10mg/2ml
-Derbyshire has moved to one preferred buccal midazolam product (Buccolam), for use in both adults
(off-licence use) and children (licensed use).
- Epistatus (10mg/1ml) is classified as Grey, when initiated by out-of-area providers.
* Existing patients on Epistatus should be reviewed by the specialist and switched to the
recommended Buccolam preparation at their next review and the patients care plan should be
updated accordingly. Do not stop the Epistatus abruptly, without the patient receiving training for
the Buccolam preparation. In line with NICE guidance diazepam rectal tubes 2.5, 5, 10mg are no
longer recommended first line for seizure control.
.
94
What drugs are used in parkinsonism and related disorders?
-Ropinirole (Ipinnia XL)
-Pramipexole MR (second-line)
-Carbidopa/entacapone/levodopa combination (Stanek and Sastravi)
-Procyclidine (Kemadrin)
95
What drugs can be used to treat alcohol dependence?
Acamprosate
Disulfiram
Naltrexone
96
Nicotine replacement products can be used to help with nicotine addiction. What tablets can be used also?
Bupropion 150mg tabs
97
Bupropion
* It is contra-indicated in patients with a history of seizures or of eating disorders, a CNS tumour, or
who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal. It should not be
prescribed to patients with other risk factors for seizures unless the potential benefit of smoking
cessation clearly outweighs the risk.
* Factors that increase the risk of seizures include concomitant administration of drugs that can
lower the seizure threshold, alcohol abuse, history of head trauma, diabetes, and use of stimulants
and anorectics.
There is a riisk of serotonin syndrome with use with other serotonergic drugs:
* if concomitant prescribing with other serotonergic drugs is clinically warranted: do not exceed the recommended dose; remind patients of the milder symptoms of serotonin syndrome at initiation of treatment and at any change of dose and the importance of seeking medical advice if they occur.
* if serotonin syndrome is suspected, either decrease the dose of bupropion or withdraw therapy depending on the severity of the symptoms
98
When would Bupropion be contraindicated?
In patients with a history of seizures or eating disorders, a CNS tumour or patients experiencing acute symptoms of alcohol or benzodiazepine withdrawal.
99
What two drugs can be used to treat opioid dependence?
Methadone
Buprenorphine
100
What are some drugs that can be used to manage and treat dementia?
Donepezil *first-line)
Galantamine
Rivastigmine
Memantine
101
Dementia
Rivastigmine is also GREEN for Parkinson’s disease Dementia Complex (PDDC) - titration and dose stabilisation to be undertaken by consultant/specialist.
-Rivastigmine 4.5mg and 6mg strength are significantly more expensive- use combination of lower strength instead.
-Donepezil orodispersible is significantly more expensive than the standard tablet formulation.
-Memantine is GREEN for patients with behavioural and psychological symptoms in dementia (BPSD), and as add on to an acetylcholinesterase inhibitor in patients with established Alzheimer's disease.
-Aspirin and vascular dementia - Low-dose aspirin can improve the prognosis of heart disease and
stroke, possibly by reducing clot formation within the blood vessels and helping to maintain or improve blood flow to the heart and brain. Many doctors assume that aspirin will also provide some benefit for people with vascular dementia (not necessarily true). Practitioners need to be aware of the risks of aspirin, such as haemorrhages, which can be fatal.
.
102
When would it be suitable to use memantine to treat dementia?
-Memantine is GREEN for patients with behavioural and psychological symptoms in dementia (BPSD), and as add on to an acetylcholinesterase inhibitor in patients with established Alzheimer's disease.
103
What are some examples of acetylcholinesterase inhibitors?
Physostigmine.
Neostigmine.
Pyridostigmine.
Ambenonium.
Demecarium.
Rivastigmine.
104
How is general anaesthesia induced?
Either a volatile drug given by inhalation or with an IV administered drug
105
How is anaesthesia maintained?
With either an IV or inhalational anaesthetic
106
What can be given following surgery to reverse the effects of neuromuscular blocking drugs?
Anticholinesterases
107
Intravenous Anaesthetics
-Can be used to induce or maintain anaesthesia
-To facilitate tracheal intubation, induction is usually followed by a neuromuscular blocking drug or a short-acting opioid.
Examples of drugs used:
-Propofol, most commonly used for both induction and maintenence.
-Thiopental, used for induction
-Etomidate
-Ketamine, rarely used
.
108
What are some examples of drugs that can be used for IV anaesthetics?
Propofol
Thiopental
Etomidate
Ketamine
109
Volatile Liquid Anaesthetics
-Used for induction and maintence of anaesthesia
-Isoflurance
-Desflurane
-Sevoflurane
.
110
What is malignant hyperthermia?
A rare but potentially lethal complication of anaesthesia. Rapid rise in temperature, increase muscle rigidity, tachycardia and acidosis. Volatile anaesthetics are the most common trigger.
Dantrolene sodium is used as treatment.
111
How do local anaesthetics work?
They cause a reversible block to conduction along nerve fibres.
112
Which local anaesthetic has the longest duration of action?
Bupivacaine hydrochloride
113
What are some examples of local anaesthetics?
Bupivacaine
Levobupivacaine
Lidocaine
Prilocaine
Ropivacaine
Tetracaine
114
Which local anaesthetic is widely used in dental procedures?
Lidocaine hydrochloride
Often used in combination with adrenaline/epinephrine.
115
Dental and Orofacial Pain
-Temporary use of analgesics until the issue is resolved
-Benzydamine hydrochloride mouthwash or spray, or paracetamol and ibuprofen.
-NSAIDs such as ibuprofen, diclofenac and aspirin are best as they have an anti-inflammatory effect, whereas paracetamol does not.
.
116
What is aspirin indicated for in terms of pain?
Headache
Transient musculoskeletal pain
Dysmenorrhoea
Pyrexia
117
Why is paracetamol preferred over aspirin now?
Aspirin has interactions with a number of drugs, especially warfarin. It is also irritating to the stomach.
118
Strong Opioids
-Morphine: can cause nausea and vomiting. Opioid of choice for severe pain
-Buprenorphine: can precipitate withdrawal symptoms
-Fentanyl
-Methadone
-Oxycodone
-Tramadol
.
119
Weak Opioids
-Codeine
-Dihydrocodeine
-Meptazinol
.
120
Post-Operative Analgesia
-Morphine is most widely used
-Opioids can be associated with nausea, urinary retention and respiratory depression.
-Patients who are dependent on opioids or have a history of drug dependence may still be treated with opioid analgesics when there is a clinical need.
121
What are the major classes of antidepressants?
Tricyclic antidepressants
SSRIs
MAOIs
122
What class of antidepressant should be considered first-line and why?
SSRIs
Better tolerated and safer in overdose
123
At the start of antidepressant treatment, how often should patients be reviewed?
Every 1-2 weeks
124
After remission of depressive symptoms, how long should the treatment be continued for?
For at least a further 6 months
125
Which antidepressant class is hyponatraemia most commonly associated with?
SSRIs
126
What causes serotonin syndrome?
Excessive central and peripheral serotonergic activity.
127
What are the three characteristic symptom categories of serotonin syndrome?
Neuromuscular hyperactivity (tremor, hyperreflexia, clonus, rigidity)
Autonomic dysfunction (tachycardia, BP changes, hyperthermia, diarrhoea)
Altered mental state (agitation, confusion, mania)
128
Failure to Respond to Antidepressant Treatment
-Failure to respond to initial treatment with an SSRI may require an increase in the dose, or switching to a different SSRI or mirtazapine. Other second-line choices include lofepramine, moclobemide, and reboxetine. Other tricyclic antidepressants and venlafaxine should be considered for more severe forms of depression; irreversible MAOIs should only be prescribed by specialists.
-Failure to respond to a second antidepressant may require the addition of another antidepressant of a different class, or use of an augmenting agent (such as lithium, aripiprazole [unlicensed], olanzapine [unlicensed], quetiapine, or risperidone [unlicensed]).
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129
Anxiety Disorders and OCD
-Acute anxiety management typically involves the use of a benzodiazepine
-Chronic anxiety (4 weeks plus) may be treated with an antidepressant- escitalopram, paroxetine or sertraline.
Panic disorder is treated with SSRIs, clomipramine or imipramine.
OCD, PTSD and social anxiety can be treated with SSRIs.
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130
What is Attention Deficit Hyperactivity Disorder (ADHD)?
A behavioural disorder characterised by hyperactivity, impulsivity and inattention, which can lead to functional impairment.
131
Non-Drug Treatment of ADHD
-Environmental modifications can help
-CBT may help people who don't want pharmacological treatment
-Diet, exercise and good nutrition
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132
Drug Treatment for ADHD
-Lisdexamfetamine mesilate OR Methylphenidate hydrochloride are recommended as first-line treatments.
-6 week trial of either drug, if no improvement then switch to the other.
-Modified-release preparations are preferred of the drugs due to improved adherence, convenience etc
-Review treatment once a year
133
What is the first-line choice for treating cluster headaches?
Sumatriptan given by subcutaneous injection (sumatriptan or zolmitriptan nasal spray if the injection is unsuitable)
134
What drugs are used for the prophylaxis of cluster headaches, if the attacks are frequent or last over 3 weeks?
Verapamil hydrochloride
Lithium
Prednisolone can be used short-term, either alone or in combination with verapamil
135
What is dementia?
A progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms, including memory loss, problems with reasoning and communication, personality changes and reduced ability to carry out daily activites.
136
Alzheimer's Disease Treatment
-Acetylcholinesterases for mild-moderate disease: Donepezil, galantamine or rivastigmine are first-line
-Memantine suitable alterantive if needed for MODERATE
-Memantine first-line in severe disease
-Progression; can add memantine
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137
Donepezil or rivastigmine can be given in Lewy body dementia
138
-Aggression in dementia should be managed with counselling. Antipsychotics should only be offered if there is a risk of them harming themselves or others. Use the lowest effective dose for the shortest time possible.
-Depression should only be treated with antidepressants if the patient had depression prior to dementia diagnosis
139
Epilepsy Control
-Seizure type, epilepsy syndrome, need for treatment, risks and benefits of treatment and the patient's characteristics
-Dosing frequency is determined by the plasma drug half-life- keep as low as possible to encourage adherence.
-Most antiepileptics are BD, but lamotrigine, perampanel, phenoarbital and phenytoin are once daily at bedtime.
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140
Management of Epilepsy
1. Monotherapy with a first-line antiepileptic
2. Try monotherapy with a different drug if first is unsuccessful
3. Combination therapy with two or more drugs may be necessary, but increases the risk of side-effects.
Prescribe a single antiepileptic drug whenever possible.
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141
Categories of Antiepilpetic Drugs
Category 1: Carbamazepine, pehnobarbital, phenytoin and primidone.
-Doctors are advised to ensure patient's are maintained on a specific manufacturer's product (brand)
Category 2: Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxycarbazepine, perampanel, rufinamide, topiramate, valproate and zonisamide.
-The need for continued supply of a particular manufacturer's product should be based on clinical judgement.
Category 3: Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine and vigabatrin.
-Usually unnecessary to ensure that patient's are maintained on a specific manufacturer's product.
-Need to ensure that the patient is happy on different branded products.
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142
For which antiepileptic drugs should patient's be maintained on a specific brand?
Carbamazepine
Phenobarbital
Phenytoin
Primidone
143
Antiepileptic Hypersensitivity Syndrome
Rare but potentially fatal syndrome associated with some antiepileptic drugs- carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone and rufinamide.
-Symptoms include fever, rash and lymphadenopathy; usually start between 1-8 weeks of exposure.
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144
Withdrawing Antiepileptic Medication
-May be decided if a patient has been seizure-free for at least two years on a medication.
-Significant risk of seizure recurrence.
-If a patient is receiving several antiepileptic drugs then only one should be stopped at a time- avoid abrupt withdrawal.
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145
Driving and Seizures
-If someone has a seizure, they must stop driving immediately and inform the DVLA.
-6 months if this was their first unprovoked seizure or a single isolated event.
-One year seizure free if someone has ESTABLISHED epilepsy in order to be able to drive.
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146
Antiepileptics and Pregnancy
-Valproate is hugely CI due to being teratogenic
-Carbamazepine, phenobarbital, phenytoin and topiramate are also CI
-Lamotrigine and levetiracetam are the safer options for pregnancy
Breast-Feeding Mothers
-Monitor infants for sedation, feeding difficulties, adequate weight gain and developmental milestones
-Mothers on epilepsy monotherapy should generally be encourage to breastfeed
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147
Focal Seizures with or without Secondary Generalisation
-Consider lamotrigine and levetiracetam as first-line for focal seizures
-If unsuccessful then consider the other.
If these are both unsuccessful then consider carbamazepine, oxcarbazepine or zonisamide.
Can then consider adjunctive treatment if none of these previous options work.
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148
What are the first-line treatments for focal seizures?
Lamotrigine or Levetiracetam
149
Tonic-Clonic Seizures
-Sodium valproate is first-line monotherapy for generalised tonic-clonic seizures in males, and females unable to have children.
-If unsuccessful, consider lamotrigine or levetiracetam as second-line (try other if the first is unsuccessful).
-First-line for women able to have children should be lamotrigine or levetiracetam.
Can then try adjunctive treatment if still unsuccessful.
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150
What is the first-line treatment for tonic-clonic seizures in men and women unable to have children?
Sodium valproate
151
What is the first-line treatment for tonic-clonic seiures in females that can have children?
Lamotrigine or levetiracetam
152
Absence Seizures
-Offer ethosuximide as the first-line
-Sodium valproate is second-line for males and females unable to have children
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153
Myoclonic Seizuures
-Sodium valproate first-line in males and females unable to have children
-Levetiracetam second-line, and first-line in females that can have children.
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154
Atonic or Tonic Seizures
-Usually seen in childhood or are associated with cerebral damage or learning dofficulties- respond poorly to traditional drugs.
-Sodium valproate first-line in males and females unable to have children.
-Lamotrigine is second line for these patient's, and first-line for females that are able to have children.
155
Anxiolytics are sedatives. True or False?
True
156
Overview of Anxiolytics and Hypnotics
-Anxiolytics (sedatives) will induce sleep when given at night, and most hypnotics will sedate when given during the day
-Dependence and tolerance can develop
-Benzodiazepines are the most commonly used anxiolytic and hypnotic.
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157
Benzodiazepine Indications
-Short-term relief (2-4 weeks) of anxiety if severe.
-Insomnia if severe and disabling.
-Withdraw gradually as abrupt withdrawal may cause confusion and convulsions.
-Withdrawal: insomnia, anxiety, tremor etc
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158
Mania and Hypomania
-Used to manage acute episodes of mania associated with bipolar disorder
-An antidepressant may also be required to manage the depression aspect of bipolar disorder: avoid in patients with rapid-cycling bipolar, rapid mood fluctuation or a recent history of mania or hypomania.
-Antipsychotics (haloperidol, olanzapine etc) can treat acute episodes of mania or hypomania.
-Olanzapine can be used for the long-term management of bipolar.
-Lithium can be used for acute episodes and long-term management: narrow therapeutic index
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Migraines
-Unilateral and pulsating
Episodic migraine: occurs less than 15 days per month
Chronic migraine: occurs at least 15 days per month
-Frequent use of medication to help with headaches can cause medication-overuse headaches.
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Migraine Treatment
-Eat regular meals, keep hydrated, sleep and exercise
-Monotherapy: Aspirin, ibuprofen or a 'triptan' drug as first line. Sumatriptan would be the first-line 'triptan'.
-Metoclopramide or prochlorperazine can relieve nausea and vomiting.
-Propranolol is first-line for prevention treatment, metoprolol or atenolol are also suitable.
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161
What monotherapy options are there for managing migraine pain?
Aspirin, ibuprofen or a 'triptan' drug, mainly sumatriptan
162
What is the first-line for prophylaxis of migraines?
Propranolol
163
What is motor neurone disease?
A neurodegenerative condition affecting the brain and spinal cord. Degeneration of the motor neurones leads to progressive muscle weakness, resulting in muscle cramps, wasting and stiffness, loss of dexterity, reduce respiratory function and cognitive dysfunction.
164
Motor Neurone Disease: Management
-No cure so focus is on managing symptoms
-Muscle cramps: Quinine is first-line, baclofen as second-line.
-Muscle spasticity or stiffness: baclofen, tizanidine or gabapentin.
-Excessive drooling: Glycopyrronium bromide
-Respiratory symptoms: opioids or benzodiazepines
165
What drug can be used first-line to manage muscle cramps in motor neurone disease?
Quinine
166
What is multiple sclerosis?
A chronic, immune-mediated, demyelinating inflammatory condition of the CNS, which affects the brain, optic nerves and spinal cord, and leads to progressive severe disability.
167
What are the three types of MS?
Relapsing-remitting
Primary-progressive
Progressive-relapsing
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Relapsing-Remitting Multiple Sclerosis
-Most common pattern
-Periods of exacerbation (relapses) followed by unpredictable periods of stability (remission)
-Relapses tend to occur once or twice a year
No cure
-Interferon beta, Teriflunomide and dimethyl fumarate are drugs that can improve quality of life.
169
What are neuromuscular bloking drugs used for?
Anaesthesia- enable light anaesthesia to be used with adequate relaxation of the muscles of the abdomen and diaphragm
170
Non-polarising Neuromuscular Blocking Drugs
-Compete with acetylcholine for receptor sites at the neuromuscular junction and their action can be reversed with anticholesterases.
-Pancuronium bromide, Rocuronium bromide, Atracurium besilate, mivacurium
Depolarising Neuromuscular Blocking Drugs
-Suxamethonium chlorode
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171
What causes neuropathic pain?
Damage to neural tissue
172
Which drugs can be used to manage neuropathic pain?
Tricyclic antidepressants, e.g. Amitriptyline, nortriptyline
Antiepileptic drugs, e.g. pregabalin and gabapentin
Opioids m ay sometimes be effective
173
What are the three physiological categories of pain?
Neuropathic
Nociceptive
Nociplastic
174
When is pain classed as chronic?
Been present for more than 12 weeks
175
What is the difference between primary and secondary pain?
Primary pain has no clear underlying condition, secondary pain is caused by an underlying condition.
176
Parkinson's Disease Management of Motor Symptoms
First line: Co-careldopa or co-beneldopa
-Risk of psychotic sympotms, excessive sleepiness.
Offer a non-ergotic dopamine-receptor agonist (pramipexole, ropinirole, rotigotine) or COMT inhibitors (entacapone or talcapone)in addition to levodopa.
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Drug Management of Non-Motor Symptoms in Parkinson's Disease
-Daytime sleepiness: Modafinil
-Postural hypotension: Midodrine hydrochloride is first-line
-Psychotic symptoms: Quetiapine can treat hallucinations and delusions. Second-line is clozapine.
-Rapid-eye movement sleep behaviour disorder: Clonazepam or melatonin
-Drooling: Glycopyrronium bromide
178
What are examples of positive symptoms of schizophrenia?
Hallucinations
Delusions
179
What are examples of negative symptoms of schizophrenia?
Emotional apathy
Social withdrawal
180
Antipsychotics are more effective at allieviating negative symptoms than positive symptoms.
True or False?
False
They are better at relieving positive symptoms
181
Schizophrenia Treatment
-Oral antipsychotic + psychological therapy- start on low dose and titrate up, optimumum dose should be continued 4-6 weeks before being deemed ineffective.
-Only prescribe one antipsychotic at a time except exceptional circumstances.
-Clozapine should be offered if schizohrenia is uncontrolled despite trying two different antipsychotic drugs (one of which should be a second-generation antipsychotic).
-Clozapine requires close monitoring
182
First-Generation Antipsychotics
-Act by blocking D2 receptors in the brain
-Can cause acute extrapyramidal symptoms and hyperprolactinaemia
-The phenothiazine derivatives: Chlorpromazepine hydrochloride, fluphenazine decanoate, levomepromazine, prochlorperazine, promazine hydrochloride and trifluoperazine.
-Also includes: haloperidol and benperidol, flupentixol, zuclopenthixol, pimozide and sulpiride.
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183
What are some examples of first-generation antipsychotics?
-The phenothiazine derivatives: Chlorpromazepine hydrochloride, fluphenazine decanoate, levomepromazine, prochlorperazine, promazine hydrochloride and trifluoperazine.
-Also includes: haloperidol and benperidol, flupentixol, zuclopenthixol, pimozide and sulpiride.
184
Second-Generation (atypical) Antipsychotics
-Act on a range of receptors and are generally associated with a lower risk of acute extrapyramidal symptoms and tardive dyskinesia than with first-generations.
-Side-effects include metabolic side-effects such as weight gain and glucose intolerance.
-Aimisulpride, aripiprazole, clozapine, risperidone, olanzapine, quetiapine, lurasidone hydrochloride, asenapine, cariprazine, paliperidone.
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185
What are some examples of second-generation antipsychotics?
Aimisulpride, aripiprazole, clozapine, risperidone, olanzapine, quetiapine, lurasidone hydrochloride, asenapine, cariprazine, paliperidone.
186
What are some examples of extrapyramidal symptoms and with which antipsychotics are they most likely to occur?
Parkinsonian symptoms (bradykinesia, trmeor)
Dystonia (muscle spasm)
Akathisia (restlessness)
Tardive dyskinesia (involuntary movements of the lips, tongue, face and jaw)
Haloperido, beperidol, fluphenazine, trifluoperazine.
187
Which antipsychotics are most likely to cause hyperprolactinaemia?
Risperiidone, amisulpride, sulpiride and first generation antipsychotics.
188
What are the clinical symptoms of hyperprolactinaemia?
Sexual dysfunction
Reduce bone mineral densitity
Menstrual disturbances
Breast enlargement
Galactorrhoea
189
Sexual dysfunction is a reported side-effec t of all antipsychotics, but risperidone, haloperidol and olanzapine have the highest prevalence.
True or false?
True
190
What is neuroleptic malignant syndrome, and what are the symptoms?
A rare but potentially fatal side-effect of all antipsychotics
-Hyperthermia, fluctuating level of consciousness, muscle rigidity, autonomic dysfunction with fever, tachycardia, sweating.
Discontinue the drug for at least 5 days.
191
Monitoring for Antipsychotics
-Measure weight at start of therapy, then weekly for first 6 weeks, then at 12 weeks, then a year and then yearly.
-Fasting blood glucose, HbA1c, lipid concentrations at baseline, 12 weeks, a year and then yearly.
-Blood pressure monitoring ^^^
-FBC, urea, electrolytes and liver function tests at the startf of therapy and then yearly.
192
Barbiturates- Phenobarbital and Primidone
Not used in absence seizures- use in generalised tonic-clonic, simple partial and myoclonic seizures.
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193
Carbamazepine and oxcarbazepine are carboxamides. Which types of epilepsy can they treat?
All types, except myoclonic epilepsy and absence seizures
194
Which type of epilepsy are gabapentin and pregabalin most effective against?
In partial seizures
195
Buprenorphine Patches
-Available as 72 hourly, 96 hourly and 7 day formulations
-Avoid sticking replacement patches on the same area for _ weeks for the 7 day patches, 7 days for the 96 and 72 hour preparations
If the patient has a fever, advise the that they may experience increased side-effects, and there is a possibility of increased absorption. The same applies for external heat, e.g. a hot bath.
3
196
Fentanyl Patches
-Change the patch every 72 hours
-Contraindicated for use in opioid-naive patients: risk of respiratory-depression
-Place patch in different area each time for several days.
If the patient has a fever, advise the that they may experience increased side-effects, and there is a possibility of increased absorption. The same applies for external heat, e.g. a hot bath.
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197
Treating Schizophrenia 1
-Antipsychotics have possible side effects including weight gain, extrapyramidal, cardiovascular, hormonal and other ones too.
-Weight, BP, pulse, fasting BG, blood lipid profile etc need to assessed prior to starting treatment.
-First generation antipsychotics (typical): extrapyramidal side effects
-Second generation (atypical): metabolic side effects such as weight gain, hyperprolactaemia
-Not 'first-line' antipsychotics: depends on patient preference
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198
Treating Schizophrenia 2
-Clozapine is an atypical antipsychotic- generally only offered to people who do not respond adequately to two other antipsychotics, and is always initiated in secondary care.
-Offer antipsychotics alongside psychological interventions.
199
Sumatriptan Dosing for Migraines
50-100mg for a dose, then a further 50-100mg after at least _ hours if required, if migraine recurs. DO NOT take second dose if you did not respond to the initial dose. Maximum of _mg per day.
If OTC purchase: no more than two 50mg tabs may be taken in 24h period, or for the same attack.
2
300
200
What are some symptoms of parkinson's disease?
Motor symptoms: tremor, rigidity, bradykinesia, dyskinesia
Non-motor symptoms: dementia, depression, hallucinations, urinary/continence problems, speech issues, sleep disturbances, swallowing difficulties, weight loss
201
What is dyskinesia?
Uncontrolled, involuntary movements
A tremor is similar, but a tremor is more regular, rhythmic movement
202
What is bradykinesia?
Slowness of movement and speech
203
Types of Drugs used to Treat/Manage Parkinson's Disease
-Drugs that increase dopamine levels in the brain
-Drugs that prevent the breakdown of dopamine
-Drugs that stimulate dopamine receptors
-Antimuscarinics
-Others
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204
Drug Therapies for Parkinson's: Increasing Dopamine Levels in the Brain
-Dopamine CANNOT cross the BBB, but levodopa (a prodrug of dopamine) can.
-However, before levodopa can reach the brain, it would be metabolised into dopamine. As a result, we have to stop the conversion of levodopa to dopamine prior to reaching the brain.
This involves the use of a decarboxylase inhibitor alongside levodopa:
-Co-careldopa (Sinemet)- Carbidopa with levodopa
-Co-beneldopa (Madopar)- Benserazide with levodopa
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205
Drug Therapies for Parkinson's Disease: Preventing the Breakdown of Dopamine
COMT inhibitors:
-Entacapone
-Opicapone
-Tolcapone
MAO-B Inhibitors:
-Rasagiline
-Selegiline
-Safinamide
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206
Drug Therapies for Parkinson's: Stimulating Dopamine Receptors
Ergot Derived:
-Bromocriptine
-Cabergoline
-Pergolide
Non-Ergot Derived
-Pramipexole
-Ropinirole
-Rotigotine
-Apomorphine
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207
Drug Therapies for Parkinson's: Antimuscarinics
-Procyclidine
-Orphenadrine
-Trihexyphenidyl
Other drugs used:
-Amantadine
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208
What is psychosis?
A loss of contact with reality, and can feature hallucinations and delusions- can occur in conditions such as schizophrenia, bipolar disorder, dementia, trauma and with certain medications or illicit drugs.
209
Schizophrenia symptoms can be categorised into 'positive' symptoms and 'negative' symptoms. What are some symptoms of schizophrenia?
Positive:
- Hallucinations
-Delusion
-Thought disorder
-Changes in behaviour
-Disorganised speech
Negative:
-Socially withdrawn
-Lack of hygiene
-Loss of interest
-Wanting to be alone
-Unable to concentrate
210
Antipsychotic Medication for Schizophrenia
First Generation (Typical)
-Chlorpromazine
-Flupentixol
-Haloperidol
-Levomepromazine
-Pericyazine
-Perphenazine
-Prochlorperazine
-Promazine
-Sulpiride
-Trifluoperazine
-Zuclopenthixol
Second Generation (Atypical)
-Amisulpride
-Aripiprazole
-Clozapine
-Olanzapine
-Paliperidone
-Quetiapine
-Risperidone
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211
Psychological Treatments for Schizophrenia
-CBT
-Psychoeducation
-Cognitive Remediation
-Family therapy
-Arts therapy
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212
Depression: Non-Drug Interventions
-Individual guided self-help
-Group-based CBT
-Individual CBT
-Interpersonal therapy
-Behavioural activation
-Counselling
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213
What are the three main neurotransmitters that are indicated in depression?
Serotonin
Noradrenaline
Dopamine
214
What are the main drug types that can be used in depression treatment?
SSRIs, such as sertraline, fluoxetine, citalopram (block re-uptake of serotonin so serotinin stays in the system longer)
MAOIs, such as isocarboxazid and phenelzine (Blocks action of MAO enzyme)
TCAs, such as amitriptyline, imipramine and nortripyline (inhibit re-uptake of both serotonin and noradrenaline.
SNRIs, such as duloxetine and venlafaxine (inhibit the re-uptake of both serotonin and noradrenaline)
Atypical antidepressants, such as mirtazepine, reboxetine, agomelatine, virtioxetine, trazodone and tryptophan.
215
Management of Breakthrough Pain in Patients on Immediate Release or MR Morphine Tablets/Capsules
-Treat with immediate release morphine- dose at 1/6th to 1/10th of the total daily oral morphine dose.
-Repeat no more than every two hours
-Onset of action is 20-30 minutes
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216
Drugs Used for Migraine Prophylaxis
Very Volatile Pharmacotherapeutic Agents For Migraine Prophylaxis
Verapamil
Valproic acid
Pizotifen
Amitriptyline
Flunarizine
Methysergide
Propranolol
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217
Pain Ladder
1. Paracetamol
2. NSAID, or a TENS machine
3. Weak opioid, such as codeine, so co-codamol
4. POM: tramadol, codeine etc
5. Morphine
6. Fentanyl, usually in palliative care
Gabapentin and Amitriptyline can be added at any stage for neuropathic pain.
218
What is the first-line antidepressant for an under 18 patient?
Fluoxetine
219
TCA'S Side-Effects Acronym
Thrombocytopenia
Cardiac (arrhythmia, MI, stroke)
Anticholinergic (tachycardua, urinary retention etc
Seizures
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220
Which foods should be avoided in patients take MAOI's? For example, meclobemide, phenelzine, isocarboxazid.
Marmite
Mature cheese
221
How can disulfiram be used in alcohol withdrawal?
Creates very unpleasant side-effects when the patient takes alcohol alongside it
222
Antimuscarinic Drugs are used to treat urinary incontinence/uncontrolled bladder. What are some examples of these drugs?
Oxybutynin
Tolterodine
Trospium
Darifenacin
Solifenacin
223
What are some of the most common side-effects of antimuscarinics?
Ataxia
Dry throat
Pupil dilation (mydriasis)
Tachycardia
Urinary retention
Increased IOP
Reduced bowel movements
224
How long should antidepressants be continued for before considering switching if there has been no benefit?
4 weeks minimum (6 weeks for the elderly)
225
Breakthrough pain dose should be managed at a dose of 1/10th - 1/6th of their daily opioid dose.
.
226
How long do butec patches last (and most buprenorphine patches)?
7 days
227
How long do fentanyl patches last?
Need replacing every 72 hours
228
What is the target plasma concentration of carbamazepine?
4-12mg/L (20-50micromol/L)
229
What are some contraindications of NSAIDs?
-History of peptic ulcerations
-GI bleeding history/active
-Asthma
-Operations associated with high blood loss
-Moderate to severe renal impairment
-Dehydration
-History of hypersensitivity to NSAIDs or aspirin.
230
Where is morphine primarily metabolised?
Liver (therefore patients with liver disease are cautioned)
231
Which anti-emetics are first choice for use in Parkinson's disease?
Domperidone
Cyclizine
Ondansetron
232
After how many weeks of use would it be necessary for a patient on benzodiazepines to be weaned off gradually?
2 weeks
233
Clozapine Monitoring
-Monitor leucocyte and differential blood counts. Clozapine requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly.
-Close medical supervision during initiation (risk of collapse because of hypotension and convulsions).
-Blood lipids and weight should be measured at baseline,every 3 months for the first year, and then yearly.
-Fasting blood glucose should be measured at baseline, at 1 month, then every 4–6 months.
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234
What is the maximum dose of ibuprofen someone can take a day, NOT OTC?
600mg QDS
OTC would be 200-400mg TDS
235
Parkinson's Disease
For first-line treatment:
-if the motor symptoms are affecting the patient's quality of life: levodopa
-if the motor symptoms are not affecting the patient's quality of life: dopamine agonist (non-ergot derived, such as bromocriptine, ropinirole) , levodopa or monoamine oxidase B (selegiline)
Can also add a COMT inhibitor, such as entacapone.
