BNF - Chapter 4 - Nervous System - (Part 1) Flashcards

Question

What is the aim of treatment of epilepsy?

Answer 1

- To prevent the occurrence of seizures by maintaining an effective dose of one or more antiepileptic drugs

Answer 2

- When choosing an antiepileptic drug, the presenting epilepsy syndrome should first be considered. If the syndrome is not clear, the seizure type should determine the choice of treatment. Concomitant medication, co-morbidity, age, and sex should also be taken into account.

Answer 3

- Lamotrigine - Perampanel - phenobarbital - Phenytoin However, with large doses, some antiepileptics may need to be given more frequently to avoid adverse effects associated with high peak plasma-drug concentration.

Answer 4

- Monotherapy with an anti-epileptic drug should be tried first - When this has failed mono-therapy with a second drug should be tried - Combination therapy with two or more anti-epileptic drugs may be necessary, but the concurrent use of antiepileptic drugs increases the risk of adverse effects and drug interactions. - Wherever possible, a single antiepileptic drug should be prescribed

Answer 5

- all antiepileptic drugs may be associated with a small increased risk of suicidal thoughts and behaviour; symptoms may occur as early as 1 week after starting treatment

Answer 6

3 categories Category 1 Category 2 Category 3

Answer 7

- Carbamazepine - Phenobarbital - Phenytoin - Primidone For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product.

Answer 8

- Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide. For these drugs, the need for continued supply of a particular manufacturer's product should be based on clinical judgement and consultation with the patient and/or carer taking into account factors such as seizure frequency, treatment history, and potential implications to the patient of having a breakthrough seizure. Non-clinical factors as for Category 3 drugs should also be considered.

Answer 9

Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin For these drugs, it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed, however, other factors are important when considering whether switching is appropriate. Differences between alternative products (e.g. product name, packaging, appearance, and taste) may be perceived negatively by patients and/or carers, and may lead to dissatisfaction, anxiety, confusion, dosing errors, and reduced adherence. In addition, difficulties for patients with co-morbid autism, mental health problems, or learning disability should also be considered.

Answer 10

carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide Some other antiepileptics (eslicarbazepine, stiripentol, and zonisamide) have a theoretical risk.

Answer 11

he symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy are most commonly seen. Other systemic signs include liver dysfunction, haematological, renal, and pulmonary abnormalities, vasculitis, and multi-organ failure. If signs or symptoms of hypersensitivity syndrome occur, the drug should be withdrawn immediately, the patient must not be re-exposed, and expert advice should be sought.

Answer 12

- only one drug should withdrawn at a time

Answer 13

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

Answer 14

Patients with established epilepsy may drive a motor vehicle provided they are not a danger to the public and are compliant with treatment and follow up.

Answer 15

To continue driving, these patients must be seizure-free for at least one year (or have a pattern of seizures established for one year where there is no influence on their level of consciousness or the ability to act); also, they must not have a history of unprovoked seizures.

Answer 16

Yes there is additional criteria (more strict - consult DVLA)

Answer 17

Patients who have had a seizure while asleep are not permitted to drive for one year from the date of each seizure, unless: a history or pattern of sleep seizures occurring only ever while asleep has been established over the course of at least one year from the date of the first sleep seizure; or an established pattern of purely asleep seizures can be demonstrated over the course of three years if the patient has previously had seizures whilst awake (or awake and asleep)

Answer 18

The DVLA recommends that patients should not drive during medication changes or withdrawal of antiepileptic drugs, and for 6 months after their last dose.

Answer 19

It will be revoked for 1 year; relicensing may be considered earlier if treatment has been reinstated for 6 months and no further seizures have occurred

Answer 20

Valproate, in particular, is highly teratogenic and evidence supports that use in pregnancy leads to congenital malformations (approximately 10% risk) and neurodevelopmental disorders (approximately 30–40% risk).

Answer 21

Prescribers are reminded that valproate must not be used in females of childbearing potential unless the conditions of the Pregnancy Prevention Programme are met and alternative treatments are ineffective or not tolerated. Valproate must not be used during pregnancy unless there is no other suitable alternative.

Answer 22

- Lamotrigine and levetiracetam large studies of pregnancies exposed to lamotrigine or levetiracetam monotherapy did not suggest an increased risk of major congenital malformations (at usual maintenance doses). however the data were inadequate to completely rule out the possibility of an increased risk.

Answer 23

- Folate supplementation folic acid 5mg

Answer 24

- Should be assess for eclampsia

Answer 25

Neonatal haemorrhage

Answer 26

the UK Epilepsy and Pregnancy Register

Answer 27

All infants should be monitored for sedation, feeding difficulties, adequate weight gain, and developmental milestones. Infants should also be monitored for adverse effects associated with the antiepileptic drug particularly with newer antiepileptics, if the antiepileptic is readily transferred into breast-milk causing high infant serum-drug concentrations (e.g. ethosuximide, lamotrigine, primidone, and zonisamide), or if slower metabolism in the infant causes drugs to accumulate (e.g. phenobarbital and lamotrigine).

Answer 28

Primidone, phenobarbital, and the benzodiazepines

Answer 29

- Phenobarbital - Primidone - Lamotrigine

Answer 30

For focal seizures: 1st Line = carbamazepine or lamotrigine (oxcarbazepine, sodium valproate and levetiracetam may be used if carbamazepine or lamotrigine are unsuitable or not tolerated) - If monotherapy is unsuccessful with two of these first-line antiepileptic drugs, adjunctive treatment may be considered. Options for adjunctive treatment include carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate, or topiramate. If adjunctive treatment is ineffective or not tolerated, a tertiary epilepsy specialist should be consulted who may consider eslicarbazepine acetate, lacosamide, phenobarbital, phenytoin, pregabalin, tiagabine, vigabatrin and zonisamide.

Answer 31

Focal = localised to one hemisphere of the brain Tonic-clonic = Tonic (body is rigid), Clonic (uncontrolled jerking) Myoclonic = shock-like jerks of muscles, Absence = spells of STARING.

Answer 32

1st line = sodium valproate (except in female patients who are premenopausal) Lamotrigine is the alternative, but may exacerbate myoclonic seizures.

Answer 33

1st line = sodium valproate (excpet for in female patients who are premenopausal). 2nd = topiramate and levetiracetam are alternative options Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine and vigabatrin are not recommended for the treatment of myoclonic seizure

Answer 34

- Ethosuximide or sodium valproate (except in female patients who are premenopausal) lamotrigine is a suitable alternative when ethosuximide and sodium valproate are unsuitable, ineffective or not tolerated Sodium valproate should be used as the first choice if there is a high risk of generalised tonic-clonic seizures. Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine and vigabatrin are not recommended in absence seizures or syndromes

Answer 35

Usually seen in childhood, in specific epilepsy syndromes or associated with cerebral damage or mental retardation

Answer 36

They may respond poorly to the traditional drugs. Sodium valproate is the drug of choice (except in female patients who are premenopausal, see Valproate below); lamotrigine can be added as adjunctive treatment. If adjunctive treatment is ineffective or not tolerated, a tertiary epilepsy specialist should be consulted, and may consider rufinamide or topiramate. Carbamazepine, gabapentin, oxcarbazepine, pregabalin, tiagabine or vigabatrin are not recommended in atonic and tonic seizures.

Answer 37

- Sodium valproate

Answer 38

Carbamazepine or lamotrigine

Answer 39

Sodium Valproate

Answer 40

Ethosuximide | Sodium valproate

Answer 41

Carbamazepine may exacerbate tonic, atonic, myoclonic and absence seizures and is therefore not recommended if these seizures are present.

Answer 42

for the treatment of focal seizures with or without secondary generalised tonic-clonic seizures. Oxcarbazepine is not recommended in tonic, atonic, absence or myoclonic seizures due to the risk of seizure exacerbation

Answer 43

- First line treatment option for absence seizures - It may also be prescribed as adjunctive treatment for absence seizures when monotherapy is ineffective Ethosuximide is also licensed for myoclonic seizures.

Answer 44

- Gabapentin and pregabalin are used for the treatment of focal seizures with or without secondary generalisation. - They are not recommended if tonic, atonic, absence or myoclonic seizures are present. Both are also licensed for the treatment of neuropathic pain. Pregabalin is licensed for the treatment of generalised anxiety disorder.

Answer 45

Lamotrigine is an antiepileptic drug recommended as a first-line treatment for focal seizures and primary and secondary generalised tonic-clonic seizures. Myoclonic seizures may be exacerbated by lamotrigine and it can cause serious rashes especially in children; dose recommendations should be adhered to closely.

Answer 46

Valproate increases plasma-lamotrigine concentration, whereas the enzyme-inducing antiepileptics reduce it; care is therefore required in choosing the appropriate initial dose and subsequent titration

Answer 47

is used for monotherapy and adjunctive treatment of focal seizures with or without secondary generalisation, and for adjunctive treatment of myoclonic seizures in patients with juvenile myoclonic epilepsy and primary generalised tonic-clonic seizures.

Answer 48

Brivaracetam is used as adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalisation.

Answer 49

Phenobarbital is effective for tonic-clonic and focal seizures but may be sedative in adults. It may be tried for atypical absence, atonic, and tonic seizures. Rebound seizures may be a problem on withdrawal.

Answer 50

Largely converted to phenobarbital and this is probably responsible for its antiepileptic action A low initial dose of primidone is essential

Answer 51

Phenytoin is licensed for tonic-clonic and focal seizures but may exacerbate absence or myoclonic seizures and should be avoided if these seizures are present. It has a narrow therapeutic index and the relationship between dose and plasma-drug concentration is non-linear; small dosage increases in some patients may produce large increases in plasma concentration with acute toxic side-effects Similarly, a few missed doses or a small change in drug absorption may result in a marked change in plasma-drug concentration. Monitoring of plasma-drug concentration improves dosage adjustment.

Answer 52

Rufinamide is licensed for the adjunctive treatment of seizures in Lennox-Gastaut syndrome

Answer 53

Zonisamide can be used alone for the treatment of focal seizures with or without secondary generalisation in adults with newly diagnosed epilepsy, and as adjunctive treatment for refractory focal seizures with or without secondary generalisation in adults and children aged 6 years and above

Answer 54

- Clobazam | - Clonazepam

Answer 55

Acetazolamide, a carbonic anhydrase inhibitor, has a specific role in treating epilepsy associated with menstruation.

Answer 56

A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death

Answer 57

- positioning the patient to avoid injury - supporting respiration including the provision of oxygen - Maintaining blood pressure - correction of any hypoglycaemia

Answer 58

If alcohol abuse is suspected

Answer 59

pyridoxine hydrochloride should be given if the status epilepticus is caused by pyridoxine hydrochloride deficiency.

Answer 60

With intravenous lorazepam (repeated once after 10 minutes if seizures recur or fail to respond).

Answer 61

Intravenous diazepam is effective but it carries a high risk of thrombophlebitis (reduced by using an emulsion formulation). Absorption of diazepam from intramuscular injection or from suppositories is too slow for treatment of status epilepticus.

Answer 62

respiratory depression and hypotension

Answer 63

diazepam can be administered as a rectal solution or midazolam oromucosal solution can be given into the buccal cavity.

Answer 64

phenytoin sodium, fosphenytoin sodium, or phenobarbital sodium should be used; contact intensive care unit if seizures continue. If these measures fail to control seizures 45 minutes after onset, anaesthesia with thiopental sodium, midazolam, or a non-barbiturate anaesthetic such as propofol [unlicensed indication], should be instituted with full intensive care support.

Answer 65

By slow intravenous injection, followed by the maintenance dosage if appropriate Alternatively, fosphenytoin sodium (a pro-drug of phenytoin), can be given more rapidly and when given intravenously causes fewer injection-site reactions than phenytoin sodium. Although it can also be given intramuscularly, absorption is too slow by this route for treatment of status epilepticus

Answer 66

in terms of phenytoin sodium

Answer 67

If there is incomplete loss of awareness, usual oral antiepileptic therapy should be continued or restarted. Patients who fail to respond to oral antiepileptic therapy or have complete lack of awareness can be treated in the same way as for convulsive status epilepticus, although anaesthesia is rarely needed

Answer 68

Febrile seizures (febrile convulsions) are fits that can happen when a child has a fever. They most often happen between the ages of 6 months and 3 years.

Answer 69

- Brief febrile convulsions need no specific treatment; antipyretic medication (e.g. paracetamol), is commonly used to reduce fever and prevent further convulsions but evidence to support this practice is lacking. Prolonged febrile convulsions (those lasting 5 minutes or longer), or recurrent febrile convulsions without recovery must be treated actively (as for convulsive status epilepticus).

Answer 70

No it is rarely indicated

Answer 71

- seizures associated with Lennox-Gastaut syndrome (adjnct treatment with clobazam) - Seizures associated with Dravet syndrome (adjunct treatment with clobazam)

Answer 72

Clobazam is not prescriable in NHS primary care except for the treatment of epilepsy, endorse prescription 'SLS'

Answer 73

Thiopental sodium

Answer 74

Slow intravenous infusion - 4mg for 1 dose, then 4mg after 10 minutes if required for 1 dose, to be administered into a large vein

Answer 75

It is a general term for several disorders that cause nervousness, fear and worrying

Answer 76

Yes they are indicated but for short term relief of anxiety that is causing unacceptable distress (for 2-4 weeks only). e.g. diazepam Lowest possible dose for shortest period of time

Answer 77

- drowsiness - Ataxia - Dysarthria - Coma

Answer 78

- may cause neonatal hypothermia, hypotonia and respiratory depression

Answer 79

- they reduce palpitations and tremors which can prevent onset of worry + fear

Answer 80

Lasting more than 4 weeks.

Answer 81

- An antidepressant

Answer 82

- Psychological treatment followed by an SSR (E.g. Escitalopram) - Duloxetine and venlafaxine (Serotonin and noradrenaline re-uptake inhibitors) can also be used. - If a patient cannot tolerate the above/ treatment is ineffective, then pregabalin can be considered

Answer 83

Antidepressant - serotonin receptor agonists

Answer 84

Anxiety (short-term use)

Answer 85

No it is CI in epilepsy

Answer 86

Alprazolam Chlordiazepoxide hydrochloride Diazepam Oxazepam

Answer 87

Attention deficit hyperactivity disorder (ADHA) is a behavioural disorder characterised by hyperactivity, impulsivity and inattention, which can lead to functional impairment such as psychological, social, educational or occupation difficulties.

Answer 88

3-7 years, but may not be recognised until after 7 years of age, especially if hyperactivity is not present.

Answer 89

more commonly diagnosed in males

Answer 90

disorders such as oppositional defiant disorder (ODD), conduct disorder, and possibly mood disorders such as depression, mania, and anxiety, as well as substance misuse

Answer 91

- balanced diet, good nutrition and regular exercise - environmental modifications such as changes to seating arrangements lighting and noise etc. ADHD focused psychological interventions which may involve elements of, or a complete course of cognitive behavioural therapy (CBT) may be effective in patients who have refused drug treatment, have difficulty with adherence, are intolerant of, or unresponsive to drug treatment. In patients who have benefited from drug treatment, but whose symptoms are still causing significant impairment in at least one area of function (such as interpersonal relationships, education and occupational attainment, and risk awareness), consider a combination of non-drug treatment with drug treatment.

Answer 92

Drug treatment should be initiated by a specialist trained in the diagnosis and management of ADHD. Following dose stabilisation, continuation and monitoring of drug treatment can be undertaken by the patient's general practitioner under a shared care arrangement.

Answer 93

Treatment should be started in patients with ADHD whose symptoms are still causing significant impairment in at least one area of function, despite environmental modifications.

Answer 94

No - should be treated the same

Answer 95

Lisdexamfetamine (Elvanse) or methylphenidate are recommended as first line If symptoms have not improved following a 6-week trial of either drug, switching to the alternative first-line treatment should be considered

Answer 96

Dexamfetamine for those who cannot tolerate lisdexamfetamine's longer duration of effect.

Answer 97

Modified-release preparations of stimulants are preferred because of their pharmacokinetic profile, convenience, improved adherence, reduced risk of drug diversion (drugs being forwarded to others for non-prescription use or misuse), and the lack of need to be taken to work. Immediate-release preparations can be given when more flexible dosing regimens are required, or during initial dose titration.

Answer 98

- A non-stimulant | Atomoxetine

Answer 99

At least once a year and trials of treatment free periods or dose reductions should be considered where appropriate.

Answer 100

Centrally acting sympthomimetics (CNS Stimulant)

Answer 101

- Concerta XL - Quasym XL - Medikinet XL - Xaggitin XL

Answer 102

Guanfacine (Alpha2 adrenoreceptor agonist)

Answer 103

1. Monitoring requirements: monitor patient for worsening of anxiety, depression or tics. Pulse, blood pressure psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment and 6 months thereafter.

Answer 104

Tics are sudden twitches, movements, or sounds that people do repeatedly. People who have tics cannot stop their body from doing these things. For example, a person with a motor tic might keep blinking over and over again. Or, a person with a vocal tic might make a grunting sound unwillingly

Answer 105

Discontinue treatment

Answer 106

Tourette Syndrome (TS) is a condition of the nervous system. TS causes people to have “tics”. Tics are sudden twitches, movements, or sounds that people do repeatedly. People who have tics cannot stop their body from doing these things

Answer 107

It is a condition that affects moods, which can swing from one extreme to another. People with bipolar disorder often have periods or episodes of: - Depression (feeling very low and lethargic - Mania (feeling very high and overactive)

Answer 108

Antimanic drugs

Answer 109

Patients with rapid-cycling bipolar disorder - a recent history of mania or hypomania or with rapid mood fluctuations (Consider stopping the antidepressant drug if the patient develops mania or hypomania

Answer 110

- Haloperidol - Olanzapine - Quetiapine - Risperidone

Answer 111

Lithium or sodium valproate

Answer 112

if there is no improvement despite optimising the dose of lithium or valproate, an antipsychotic drug can be added to treat the acute episode of mania or hypomania.

Answer 113

It is a second generation antipsychotic drug, it is licensed for the treatment of moderate to severe manic episodes associated with bipolar disorder

Answer 114

- Olanzapine | - it is licensed for the prevention of recurrence in patients whose manic episode has responded to olanzapine therapy

Answer 115

The dose should be reduced gradually over at least 4 weeks to minimise the risk of recurrence

Answer 116

- use of benzodiazepines (such as lorazepam) may be helpful in the initial stages of treatment for behavioural disturbances or agitation. - They should not be used for long periods because of the risk of dependence.

Answer 117

Lithium carbonate | Lithium Citrate

Answer 118

Lithium is used for the treatment of acute episodes of mania or hypomania in bipolar disorder. Lithium is also used for the long-term management of bipolar disorder to prevent recurrence of acute episodes.

Answer 119

must be based on careful consideration of the likelihood of recurrence in the individual patient, and the benefit of treatment weighed against the risks

Answer 120

- six to twelve months after initiation of therapy

Answer 121

Valproate (valproic acid (as the semisodium salt) and sodium valproate) It is used for the treatment of manic episodes associated with bipolar disorder if lithium is not tolerated or contra-indicated. Valproate is also used for the long-term management of bipolar disorder to prevent recurrence of acute episodes, in combination with lithium if treatment with lithium alone is ineffective, or as monotherapy if lithium is not tolerated or contra-indicated.

Answer 122

It is licensed for the long-term management of bipolar disorder, to prevent recurrence of acute episodes in patients unresponsive to lithium therapy.

Answer 123

- thyroid disorders and mild cognitive and memory impairment | thyroid function should be monitored every 6 months- more frequently if there is evidence of deterioration

Answer 124

12 hours after a dose

Answer 125

0. 4-1mmol/L (lower end of the range for maintenance therapy and elderly patients). 0. 8-1mmol/L is recommended for acute episodes of mania, and for patients who have previously relapsed or have sub-syndromal symptoms.

Answer 126

Routine serum-lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, then every 3 months for the first year then every 6 months thereafter. Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months during treatment and more often if there is evidence of impaired renal or thyroid function, or raised calcium levels.

Answer 127

Gradually over at least 4 weeks (preferably over 3 months)

Answer 128

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning.

Answer 129

Improvement

Answer 130

(lower grade chronic depression) - Typically of at least 2 years duration. Antidepressant drugs are also effective for dysthymia

Answer 131

No - should not be used routinely in mild depression and psychological therapy should be considered initially; however, a trial of antidepressant therapy may be considered in cases refractory to psychological treatments or in those associated with psychosocial or medical problems.

Answer 132

- Tricyclic and related antidepressants - selective serotonin re-uptake inhibitors (SSRIs) - Monoamine oxidase inhibitors (MAOIs)

Answer 133

No there is little to choose between them in terms of efficacy. Choice should be based on the individual patient's requirements, including the presence of concomitant disease, existing therapy, suicide risk, and previous response to antidepressant therapy.

Answer 134

electroconvulsive treatment may be required in severe depression when delay is hazardous or intolerable.

Answer 135

there is an increased potential for agitation, anxiety, and suicidal ideation.

Answer 136

SSRIs - 1st line They are better tolerated and are safer in overdose than other classes of antidepressants.

Answer 137

Sertraline

Answer 138

They have similar efficacy to SSRIs but are more likely to be discontinued because of side-effects; toxicity in overdose is also a problem SSRIs are less sedating and have fewer antimuscarinic and cardiotoxic effects than tricyclic antidepressants.

Answer 139

They have dangerous interactions with some foods and drugs and should be reserved for use by specialists

Answer 140

They may mask the true diagnosis but they are useful adjuncts in agitated patients

Answer 141

St John’s wort (Hypericum perforatum) is a popular herbal remedy on sale to the public for treating mild depression

Answer 142

because St John’s wort can induce drug metabolising enzymes and a number of important interactions with conventional drugs, including conventional antidepressants, have been identified Furthermore, the amount of active ingredient varies between different preparations of St John’s wort and switching from one to another can change the degree of enzyme induction.

Answer 143

the concentration of the interacting drugs may increase, leading to toxicity (St John's Wort is a metabolising enzyme inducer)

Answer 144

- Every 1-2 weeks at the start

Answer 145

Treatment should be continued for at least 4 weeks (6 weeks in the elderly) In cases of partial response, continue for a further 2-4 weeks.

Answer 146

- should be continued at the same dose for at least 6 months (about 12 months in the elderly) - or for at least 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high)

Answer 147

For at least 2 years

Answer 148

- Hyponatraemia (usually in the elderly and possibly due to inappropriate secretion of antidiuretic hormone) More frequently reported with SSRIs than other antidepressants.

Answer 149

If patient develops: - Drowsiness - Confusion - Convulsions

Answer 150

Serotonin syndrome or serotonin toxicity is a relatively uncommon adverse drug reaction caused by excessive central and peripheral serotonergic activity. Onset of symptoms, which range from mild to lifethreatening, can occur within hours or days following the initiation, dose escalation, or overdose of a serotonergic drug, the addition of a new serotonergic drug, or the replacement of one serotonergic drug by another without allowing a long enough washout period in-between, particularly when the first drug is an irreversible MAOI or a drug with a long half-life. Severe toxicity, which is a medical emergency, usually occurs with a combination of serotonergic drugs, one of which is generally an MAOI

Answer 151

The characteristic symptoms of serotonin syndrome fall into 3 main areas, although features from each group may not be seen in all patients—neuromuscular hyperactivity (such as tremor, hyperreflexia, clonus, myoclonus, rigidity), autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea), and altered mental state (agitation, confusion, mania).

Answer 152

Treatment consists of withdrawal of the serotonergic medication and supportive care; specialist advice should be sought.

Answer 153

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.

Answer 154

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]), but such adjunctive treatment should be initiated only by doctors with special experience of these combinations. Electroconvulsive therapy may be initiated in severe refractory depression.

Answer 155

Management of acute anxiety generally involves the use of a benzodiazepine or buspirone hydrochloride.

Answer 156

Antidepressants Combined therapy with a benzodiazepine may be required until the antidepressant takes effect.

Answer 157

should be offered psychological treatment before initiating an antidepressant. If drug treatment is needed, an SSRI such as escitalopram, paroxetine, or sertraline [unlicensed], can be used Duloxetine and venlafaxine (serotonin and noradrenaline reuptake inhibitors (SNRIs)) are also recommended for the treatment of generalised anxiety disorder if the patient cannot tolerate SSRIs or SNRIs (or if treatment has failed to control symptoms), pregabalin can be considered.

Answer 158

Panic disorder is treated with SSRIs; clomipramine hydrochloride [unlicensed] or imipramine hydrochloride [unlicensed] can be used second-line. Venlafaxine, an SNRI, is also licensed for panic disorder.

Answer 159

SSRIs Clomipramine hydrochloride can be used second-line for obsessive-compulsive disorder.

Answer 160

Moclobemide is licensed for the treatment of social anxiety disorder.

Answer 161

They block the re-uptake of both serotonin and noradrenaline, although to different extents

Answer 162

Clomipramine - more selective for serotonergic transmission Imipramine - more selective for noradrenergic transmission

Answer 163

Those with additional sedative properties and those that are less sedating.

Answer 164

Sedative compounds

Answer 165

tend to respond better to less sedative ones

Answer 166

amitriptyline hydrochloride, clomipramine hydrochloride, dosulepin hydrochloride, doxepin, mianserin hydrochloride, trazodone hydrochloride, and trimipramine

Answer 167

Those with less sedative properties include imipramine hydrochloride, lofepramine, and nortriptyline.

Answer 168

varying degrees of antimuscarinic side-effects and cardiotoxicity in overdosage, which may be important in individual patients.

Answer 169

Lofepramine has a lower incidence of side-effects and is less dangerous in overdosage but is infrequently associated with hepatic toxicity

Answer 170

Imipramine hydrochloride is also well established, but has more marked antimuscarinic side-effects than other tricyclic and related antidepressants

Answer 171

Amitriptyline hydrochloride and dosulepin hydrochloride are effective but they are particularly dangerous in over-dosage and are not recommended for the treatment of depression; dosulepin hydrochloride should be initiated by a specialist.

Answer 172

It is unnecessary as the long half-life of tricyclic antidepressant drugs allows once-daily administration; usually at night

Answer 173

if prescribed in those with dementia, narrow angle glaucoma, cardiac conduction abnormalities, prostatism, or history of urinary retention (risk of worsening these conditions); if initiated as first-line antidepressant treatment (higher risk of adverse drug reactions than with SSRIs or SNRIs).

Answer 174

because of the dangers of dietary and drug interactions and the fact that it is easier to prescribe MAOIs when tricyclic antidepressants have been unsuccessful than vice versa.

Answer 175

Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid and is more likely to cause a hypertensive crisis.

Answer 176

Isocarboxazid and phenelzine are more likely to cause hepatotoxicity than tranylcypromine.

Answer 177

Moclobemide should be reserved as a second line treatment. It is also used for social anxiety disorder

Answer 178

Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features are said to respond best to MAOIs. However, MAOIs should be tried in any patients who are refractory to treatment with other antidepressants as there is occasionally a dramatic response.

Answer 179

Response to treatment may be delayed for 3 weeks or more and may take an additional 1 or 2 weeks to become maximal.

Answer 180

- should not be started for 2 weeks after treatment with MAOIs has been stopped (3 weeks if starting clomipramine or imipramine).

Answer 181

an MAOI should not be started until: at least 2 weeks after a previous MAOI has been stopped (then started at a reduced dose) at least 7–14 days after a tricyclic or related antidepressant (3 weeks in the case of clomipramine or imipramine) has been stopped at least a week after an SSRI or related antidepressant (at least 5 weeks in the case of fluoxetine) has been stopped

Answer 182

The thioxanthene flupentixol (Fluanxol ®) has antidepressant properties when given by mouth in low doses. Flupentixol is also used for the treatment of psychoses

Answer 183

Vortioxetine, an antidepressant thought to directly modulate serotonergic receptor activity and inhibit the re-uptake of serotonin

Answer 184

- Tryptophan It should be initiated by hospital specialists

Answer 185

Melatonin receptor agonist

Answer 186

It is a melatonin receptor agonist and a selective serotonin-receptor antagnoist; it does not affect the uptake of serotonin, noradrenaline or dopamine

Answer 187

Major depression

Answer 188

MAOIs inhibit monoamine oxidase, thereby causing an accumulation of amine neurotransmitters

Answer 189

- Isocarboaxazid - Phenelzine - Tranylcypromine

Answer 190

Meclobemide

Answer 191

Raboxetine

Answer 192

Pooly controlled epilepsy | Should not be used in patients if they enter a manic phase

Answer 193

Hyponatraemia

Answer 194

QT prolongation

Answer 195

``` Citaloptam Escitaloptam Fluoxetine Fluvoxamine maleate Paroxetine Sertraline ```

Answer 196

QT prolongation

Answer 197

Paroxetine

Answer 198

Serotonin and noradrenaline reuptake inhibitors

Answer 199

Duloxetine | Venlafaxine

Answer 200

Trazadone hydrochloride

Answer 201

Mianserin hydrochloride | Mirtazepine

Answer 202

``` Amitriptyline Clomipramine Dosulepin Doxepin Imipramine Lofepramine Nortriptyline Trimipramine ```

Answer 203

Tryotophan is an essential dietary amino acid, and is a precusor of serotonin; it re-establishes the inhibitory action of serotonin on the amygdaloid nuclei, thereby reducing feelings of anxiety and depression.

Answer 204

Benperidol

Answer 205

-4 weeks | 6 weeks in elderly

Answer 206

As they are safer in overdose than other antidepressants

Answer 207

- SSRI 1st line - If a patient fails to respond to initial treatment with an SSRI, consider switching to a different SSRI or Mirtazapine - Second-line treatment choices include Venlafaxine (serotonin and noradrenaline re-uptake inhibitor) + Tricyclics. Failure to respond to a second antidepressant may require addition of an augmenting agent (top-up drug) such as Lithium or Olanzapine. - ECT may be initiated in severe refractory depression.

Answer 208

- Both serotonin and noradrenaline

Answer 209

- Amitriptyline

Answer 210

- If a patient fails to respond to initial treatment with an SSRI, consider switching to a different SSRI or Mirtazapine - Second-line treatment choices include Venlafaxine (serotonin and noradrenaline re-uptake inhibitor) + Tricyclics. Failure to respond to a second antidepressant may require addition of an augmenting agent (top-up drug) such as Lithium or Olanzapine. - ECT may be initiated in severe refractory depression.

Answer 211

- dry mouth - blurred vision - Urinary retention and constipation

Answer 212

Warfarin - either increasing or decreasing INR | It may also interact with epileptics

Answer 213

Only fluoxetine

Answer 214

Symptoms include neuromuscular hyperactivity (tremor, muscle spasm, rigidity, etc.), autonomic dysfunction (tachycardia, hyper/hypotension, hyperthermia, etc.) and altered mental state (agitation, confusion and mania

Answer 215

SSRIs may interact with drugs which increase the risk of bleeding including Warfarin, Antiepileptics and other antidepressants/antipsychotics.

Answer 216

- Paroxetine and venlafaxine

Answer 217

At a week after an SSRI has been stopped (at least 5 weeks in the case of fluoxetine)

Answer 218

- Dark Urine - Light coloured stools - Jaundice - Pruiritis

Answer 219

Neuroleptics - previously known as major tranquillisers

Answer 220

A number of mental health disorders - Mainly schizophrenia and bipolar disorder (sometimes called manic depression), - also may be used in severe or difficult to treat anxiety or depression

Answer 221

Schizophrenia is a serious mental disorder in which people interpret reality abnormally.

Answer 222

The symptoms of psychosis and schizophrenia are usually divided into 'positive symptoms' such as hallucinations and delusions, and 'negative symptoms' such as emotional apathy and social withdrawal.

Answer 223

Antipsychotic drugs are effective in the treatment of acute schizophrenic episodes; they are more effective at alleviating positive symptoms than negative symptoms.

Answer 224

An oral antipsychotic drug in combination with psychological therapy should be offered to patients with schizophrenia. The choice of drug depends on factors such as the potential to cause extrapyramidal symptoms (including akathisia), cardiovascular adverse effects, metabolic adverse effects (including weight gain and diabetes), hormonal adverse effects (including increase in prolactin concentration), and patient and carer preference.

Answer 225

optimum dose for 4-6 weeks

Answer 226

No should be avoided except in exceptional circumstances (e.g. clozapine augmentation or when changing medication during titration) because of the increased risk of adverse effects such as extrapyramidal symptoms, QT-interval prolongation, and sudden cardiac death.

Answer 227

Clozapine should be offered if schizophrenia is not controlled despite the sequential use of at least 2 different antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for an adequate duration.

Answer 228

If symptoms do not respond adequately to an optimised dose of clozapine, consider other causes of non-response (e.g. adherence to therapy, concurrent use of other drugs), review diagnosis, and check plasma-clozapine concentration before adding a second antipsychotic drug to augment clozapine; allow 8–10 weeks’ treatment to assess response. Patients must be registered with a clozapine patient monitoring service.

Answer 229

Where it is a clinical priority to avoid non-adherence

Answer 230

- Also known as typical or conventional

Answer 231

Predominantly work by blocking dopamine D2 receptors They are more likely to cause a range of side-effects, particularly acute extrapyramidal symptoms and hyperprolactinaemia.

Answer 232

phenothiazine derivatives (chlorpromazine hydrochloride, fluphenazine decanoate, levomepromazine, pericyazine, prochlorperazine, promazine hydrochloride, and trifluoperazine), the butyrophenones (benperidol and haloperidol), the thioxanthenes (flupentixol and zuclopenthixol), the diphenylbutylpiperidines (pimozide) and the substituted benzamides (sulpiride).

Answer 233

(also referred to as atypical) act on a range of receptors in comparison to first-generation antipsychotic drugs They work by blocking D2 dopamine receptors as well as serotonin receptor antagonist action. 5-HT2A subtype of serotonin receptor is most commonly involved

Answer 234

generally associated with a lower risk for acute extrapyramidal symptoms and tardive dyskinesia; the extent varies between individual drugs. However, second-generation antipsychotic drugs are associated with several other important adverse effects, such as weight gain and glucose intolerance.

Answer 235

amisulpride, aripiprazole, asenapine, cariprazine, clozapine, lurasidone hydrochloride, olanzapine, paliperidone, quetiapine, and risperidone.

Answer 236

AS a total daily dose of a single antipsychotic drug which exceeds the maximum licensed dose with respect to the age of the patient and indication being treated, and a total daily dose of two or more antipsychotic drugs which exceeds the maximum licensed dose using the percentage method

Answer 237

There is no robust evidence that high doses of antipsychotic drug treatment is any more effective than standard doses for the treatment of schizophrenia.

Answer 238

the aim of treatment is to calm and sedate the patient without inducing sleep.

Answer 239

Monitor patient every 15 minutes

Answer 240

The use of antipsychotic drugs are associated with a small increased risk of mortality and an increased risk of stroke or transient ischaemic attack

Answer 241

should not be used in elderly patients with dementia, unless they are at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress.

Answer 242

- Regularly, at least every 6 weeks (earlier for in patients)

Answer 243

a reduction in dose or the discontinuation of long-term antipsychotic treatment; review of the patient's condition after dose reduction or discontinuation of an antipsychotic drug; referral to a psychiatrist experienced in working with patients who have learning disabilities and mental health problems; annual documentation of the reasons for continuing a prescription if the antipsychotic drug is not reduced in dose or discontinued.

Answer 244

No only little difference (other than clozapine)

Answer 245

YEs and are most liekly to occur with high doses of high-potency first generation antipsychotics drugs such as piperazine phenothiazines, benperidol and haloperidol), and the first generation depot preparations.

Answer 246

More common with 1st generation antipsychotics.

Answer 247

- parkinsonian symptoms (including bradykinesia, tremor), which may occur more commonly in elderly females or those with pre-existing neurological damage such as stroke, and may appear gradually; - dystonia (uncontrolled muscle spasm in any part of the body), which occurs more commonly in young males; acute dystonia can appear within hours of starting antipsychotics; - akathisia (restlessness), which characteristically occurs within hours to weeks of starting antipsychotic treatment or on dose increase and may be mistaken for psychotic agitation; - tardive dyskinesia (abnormal involuntary movements of lips, tongue, face, and jaw), which can develop on long-term or high-dose therapy, or even after discontinuation; in some patients it can be irreversible.

Answer 248

Although antimuscarinic drugs can relieve symptom burden, they should not be routinely prescribed for prophylaxis with antipsychotic drugs.

Answer 249

Tardive dyskinesia is the most serious manifestation of late-onset extrapyramidal symptoms for which there is no satisfactory treatment

Answer 250

it occurs more commonly in elderly females

Answer 251

Most antipsychotic drugs, both first- and second-generation, increase prolactin concentration to some extent because dopamine inhibits prolactin release.

Answer 252

Aripiprazole reduces prolactin concentration in a dose-dependent manner as it is a dopamine-receptor partial agonist.

Answer 253

- Risperidone - amisulpride - first generation antipsychotic drugs

Answer 254

- aripiprazole - asenapine - Cariprazine - Clozapine - Quetiapine

Answer 255

sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea, and a possible increased risk of breast cancer.

Answer 256

Galactorrhoea is milky secretion from the breasts. The term usually refers to milk secretion not due to breastfeeding.

Answer 257

- Risperidone - Haloperidol - Olanzapine

Answer 258

- Aripiprazole | - Quetiapine

Answer 259

Expert sources advise to consider dose reduction or discontinuation (where appropriate), or switching medication if sexual dysfunction is thought to be antipsychotic-induced.

Answer 260

- tachycardia - arrhythmias - Hypotension

Answer 261

QT-interval prolongation is a particular concern with pimozide. Overall risk is probably dose-related but there is also a higher probability of QT-interval prolongation in patients using any intravenous antipsychotic drug, or any antipsychotic drug or combination of antipsychotic drugs with doses exceeding the recommended maximum.

Answer 262

aripiprazole, asenapine, clozapine, flupentixol, fluphenazine decanoate, loxapine, olanzapine, paliperidone, prochlorperazine, risperidone, and sulpiride.

Answer 263

Postural hypotension is a common cardiac side-effect of antipsychotic drugs, usually presenting acutely during the initial dose titration; however, it can also be a chronic problem.

Answer 264

The second-generation antipsychotics most likely to cause postural hypotension are clozapine and quetiapine. Slow dose titration is commonly used to minimise postural hypotension.

Answer 265

Schizophrenia is associated with insulin resistance and diabetes; the risk of diabetes is probably increased in all patients with schizophrenia who take antipsychotic drugs.

Answer 266

Some evidence suggests first-generation antipsychotic drugs are less likely to cause diabetes than second-generation antipsychotic drugs, and of the first-generation antipsychotic drugs, fluphenazine decanoate and haloperidol have the lowest risk. Amisulpride and aripiprazole have the lowest risk of diabetes of the second-generation antipsychotic drugs.

Answer 267

All antipsychotic drugs may cause weight gain, but the risk and extent varies. Clozapine and olanzapine commonly cause weight gain.

Answer 268

Amisulpride, asenapine, aripiprazole, cariprazine, haloperidol, lurasidone hydrochloride, sulpiride, and trifluoperazine are least likely to cause weight gain.

Answer 269

Neuroleptic malignant syndrome (hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with fever, tachycardia, labile blood pressure, and sweating) is a rare but potentially fatal side-effect of all antipsychotic drugs.

Answer 270

Expert sources advise discontinuation of the antipsychotic drug is essential for at least 5 days, preferably longer. The signs and symptoms of neuroleptic malignant syndrome should be allowed to resolve completely. Bromocriptine and dantrolene have been used for treatment.

Answer 271

Weight should be measured at the start of therapy with antipsychotic drugs, then weekly for the first 6 weeks, then at 12 weeks, at 1 year, and then yearly.

Answer 272

Fasting blood glucose, HbA1c, and blood lipid concentrations should be measured at baseline, at 12 weeks, at 1 year, and then yearly. Prolactin concentrations should also be measured at baseline. Before initiating antipsychotic drugs, an ECG may be required, particularly if physical examination identifies cardiovascular risk factors (e.g. high blood pressure), if there is a personal history of cardiovascular disease, or if the patient is being admitted as an inpatient. Blood pressure monitoring is advised before starting therapy, at 12 weeks, at 1 year and then yearly during treatment and dose titration of antipsychotic drugs. Expert sources advise to monitor full blood count, urea and electrolytes, and liver function tests at the start of therapy with antipsychotic drugs, and then yearly thereafter

Answer 273

Yes with first generation depot injections

Answer 274

- Aripiprazole - paliperidone - Risperidone - Olanzapine embonate

Answer 275

zuclopenthixol decanoate may be more effective in preventing relapses than other first-generation antipsychotic depot preparations.

Answer 276

Regular clinical monitoring of endocrine function should be considered when children are taking antipsychotics known to increase prolactin levels; this includes measuring weight and height, assessing sexual maturation, and monitoring menstrual function.

Answer 277

May occur with higher doses and patients should avoid direct sunlight.

Answer 278

``` Chlorpromazine Flupentixol Haloperidol Loxapine Pericyazine (periciazine) prochlorperazine Pimozide Sulpride Trifluoperazine Zuclopenthixol ```

Answer 279

Flupentixol decanoate Fluphenazine Haloperidol Zuclopenthixol decanoate

Answer 280

``` Amisulpride Aripiprazole Cariprazine Clozapine Lurasidone Olanzapine Paliperidoe Quetiapine Risperidone ```

Answer 281

Olanzapine embonate

Answer 282

Varying degrees of impariment of intestinal peristalsis

Answer 283

When a patient stops smoking or switches to an e-cigarette concomitant medicines may interact to increase blood clozapine levels if a patient has pneumonia or other serious infection reduced clozapine metabolism suspected toxicity is suspected

Answer 284

- Leucocyte and differential blood counts must be normal before starting, monitor counts every week for 18 weeks and then at least every 2 weeks and if clozapine continued and blood count stable after 1 year at least every 4 weeks (and 4 weeks after discontinuation)/

Answer 285

Treatment should be discontinued

Answer 286

It is a group of permanent, non-progressive abnormalities of the developing fetal or neonatal brain that lead to movement and posture disorders, causing activity limitation and functional impact.

Answer 287

disturbances of sensation, perception, cognition, communication and behaviour, epilepsy, and secondary musculoskeletal problems (such as muscle contracture and abnormal torsion).

Answer 288

No it is not and the comorbidities can impact on many areas of participation and quality of life, particularly eating, drinking, comfort and sleep.

Answer 289

IT is a neurodegenerative condition affecting brain and spinal cord. Degeneration of the motor neurones leads to progressive muscle weakness;

Answer 290

- muscle cramps, wasting and stiffness, loss of dexterity, reduced respiratory function and cognitive dysfunction.

Answer 291

amyotrophic lateral sclerosis

Answer 292

Neurologist without delay

Answer 293

No - therefore aim of treatment focuses on maintaining functional ability and managing symptoms

Answer 294

Quinine [unlicensed indication] is recommended as first line treatment for muscle cramps. If quinine is ineffective, not tolerated or contra-indicated, baclofen [unlicensed indication] should be considered as second line treatment. Subsequent treatment options include tizanidine [unlicensed indication], dantrolene sodium [unlicensed indication] or gabapentin [unlicensed indication].

Answer 295

baclofen, tizanidine, dantrolene sodium or gabapentin [unlicensed indication].

Answer 296

- Glycopyrronium bromide in patients who have cognitive impairment as it has fewer central nervous system side effects

Answer 297

Riluzole to extend life or to extend the time to mechanical ventilation

Answer 298

Precipitate coma

Answer 299

Abnormal face + body movements

Answer 300

Impaired voluntary movements

Answer 301

should not be given with other antipsychotics, TCAs or other drugs which prolong the QT interval and should not be given with drugs that cause electrolyte disturbances (especially diuretics)

Answer 302

Huntington's chorea and related disorders Can also be prescribed for the treatment of tardive dyskinesia if switching or withdrawing the causative antipsychotic drug is not effective

Answer 303

IT works by depleting nerve endings of dopamine

Answer 304

It is effective in only a proportion of patients and its use may be limited by the development of depression.

Answer 305

Haloperidol Pimozide (unlicensed) sulpride (unlicesed)

Answer 306

Parkinson's disease is a progressive neurodegenerative condition resulting from the death of dopaminergic cells of the substantia nigra in the brain.

Answer 307

- Motor symptoms including hypokinesia, bradykinesia, rigidity, rest tremor and postural instability

Answer 308

depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss

Answer 309

Yes and thier car insurer

Answer 310

In early stages of Parkinson's disease, patients whose motor symptoms decrease their quality of life should be offered levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa).

Answer 311

a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

Answer 312

psychotic symptoms, excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists, and impulse control disorders with all dopaminergic therapy (especially dopamine-receptor agonists)

Answer 313

Levodopa treatment is associated with motor complications, including response fluctuations and dyskinesias.

Answer 314

More noticeable with levodopa however, motor complications are less likely to occur with dopamine receptor agonists when used alone long-term.

Answer 315

the potential risk for acute akinesia or neuroleptic malignant syndrome

Answer 316

offered a choice of non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine), monoamine oxidase B inhibitors (rasagiline or selegiline hydrochloride) or COMT inhibitors (entacapone or tolcapone) as an adjunct to levodopa.

Answer 317

An ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) should only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist.

Answer 318

- Amantadine

Answer 319

Should have their Parkinson's drug treatment adjusted under specialist medical guidance

Answer 320

If reversible pharmacological and physical causes have been excluded, modafinil should be considered to treat excessive daytime sleepiness, and treatment should be reviewed at least every 12 months.

Answer 321

When treating nocturnal akinesia in patients with Parkinson's disease, levodopa or oral dopamine-receptor agonists should be considered as first-line options and rotigotine as second-line (if both levodopa or oral dopamine-receptor agonists are ineffective).

Answer 322

midodrine hydrochloride should be considered as the first option and fludrocortisone acetate [unlicensed indication] as an alternative.

Answer 323

Parkinson's disease should only be considered if non-drug treatment such as speech and language therapy is not available or is ineffective.

Answer 324

- Rivastigmine capsules or oral solution

Answer 325

Apomorphine hydrochloride as intermittent injections or continuous subcutaneous infusions

Answer 326

Impulse control disorders (compulsive gambling, hypersexuality, binge eating, or obsessive shopping) When managing impulse control disorders, dopamine-receptor agonist doses should be reduced gradually and patients should be monitored for symptoms of dopamine agonist withdrawal. Specialist cognitive behavioural therapy should be offered if modifying dopaminergic therapy is not effective.

Answer 327

Parkinsonism

Answer 328

Procyclidine exerts its antiparkinsonian action by reducing the effects of the relative central cholinergic excess that occurs as a result of dopamine deficiency.

Answer 329

- Entacapone - Opicapone - Tolcapone

Answer 330

- Co-beneldopa | - Co-careldopa

Answer 331

- Treatemtn with these drugs has been associated with impulse control disorders, including pathological gambling, binge eating, and hypersexuality. Patients and their carers should be informed about the risk of impulse control disorders Dopamine dysregulation syndrome

Answer 332

Dopamine dysregulation syndrome (DDS) is a dysfunction of the reward system observed in some individuals taking dopaminergic medications for an extended length of time. It typically occurs in people with Parkinson's disease (PD) who have taken dopamine agonist medications for an extended period of time. Addiction like symptoms should be reported

Answer 333

Levodopa with carbidopa and entacapone

Answer 334

It is a dopaminergic drug - dopamine receptor agonists

Answer 335

Amantadine is a weak dopamine agonist with modest antiparkinsonian effects

Answer 336

No it will not

Answer 337

- Prevention of lactation/ supression of lactation/ hypogonadism/ galactorrhoea/ infertility prolactinoma Parkinson's disease

Answer 338

It is a stimulant of dopamine receptors in the brain; it also inhibits release of prolactin by the pituitary.

Answer 339

It has been associated with pumonary retroperitoneal and pericardial fibrotic reactions. Exclude supression of lactation echocardiography before starting treatment

Answer 340

- Caution - provide contraceptive advice if appropriate (oral contraceptives may increase prolactin concentration)

Answer 341

- Cabergoline

Answer 342

Pramipexole Also used for parkinson's disease

Answer 343

- Ropinirole | - Rotigotine

Answer 344

Rasagiline Safinamide Selegiline hydrochloride

Answer 345

Yes, Antiemetics are generally only prescribed when the cause of vomiting is known because otherwise, they may delay diagnosis, particularly in children.

Answer 346

Cinnarizine Cyclizine Promethazine hydrochloride Promethazine teoclate

Answer 347

- Chlorpromazine - Prochlorperazine - Trifluoperazine

Answer 348

- They are dopamine antagonists and act centrally by blocking the chemoreceptor trigger zone

Answer 349

- Severe dystonic reactions

Answer 350

Prochlorperazine - It is less sedating and available as a buccal tablet

Answer 351

- Levomepromazine | - Haloperidol (unlicensed)

Answer 352

- acts directly on the gastric smooth muscle stimulating gastric emptying and it may be superior to the phenothiazines for emesis

Answer 353

- Acts at the chemoreceptor trigger zone - It has the advantage over metoclopramide hydrochloride and the phenothiazines of being less likely to cause central effects, such as sedation and dystonic reactions, because it does not readily cross the blood-brain barrier.

Answer 354

- Low dose domperidone can be used to treat nausea caused by dopaminergic drugs

Answer 355

- Granisetron - Ondansetron - Palonosetron

Answer 356

Dexamethasone Can be used alone or in combination with other antiemetics

Answer 357

- Aprepitant - Fosaprepitant They are usually given in combination with dexamethasone and a 5HT3-receptor antagonist

Answer 358

Nabilone - It can be considered as an add on treatment for chemotherapy-induced nausea and vomiting unresponsive to optimised conventional antiemetics.

Answer 359

Antiemetics should be considered for women with persistent symptoms where self-care measures have been ineffective. If a non-pharmacological option is preferred, ginger may be helpful for mild to moderate nausea.

Answer 360

chlorpromazine hydrochloride, cyclizine, doxylamine with pyridoxine, metoclopramide hydrochloride, prochlorperazine, promethazine hydrochloride, promethazine teoclate, and ondansetron.

Answer 361

Hyperemesis gravidarum is a more serious condition, which requires regular antiemetic therapy, intravenous fluid and electrolyte replacement, and sometimes nutritional support. For women with severe or persistent hyperemesis gravidarum, antiemetics given by the parenteral or rectal routes may be more suitable than the oral route.

Answer 362

Supplementation with thiamine must be considered in order to reduce the risk of Wernicke’s encephalopathy.

Answer 363

depends on many factors including the anaesthetic used, and the type and duration of surgery. Other risk factors include female sex, younger age, non-smokers, a history of postoperative nausea and vomiting or motion sickness, and intraoperative and postoperative use of opioids.

Answer 364

A combination of two or more antiemetic drugs that have different mechanisms of action is often indicated in those with risk factors for postoperative nausea and vomiting.

Answer 365

5 HT3 receptor antagonists (e.g. granisetron, ondansetron) ``` Dexamethasone droperidol hloperidol Cyclizine Prochlorperazine ```

Answer 366

Cyclizine is licensed for the prevention and treatment of postoperative nausea and vomiting caused by opioids and general anaesthetics.

Answer 367

For prevention and treatment of nausea and vomiting

Answer 368

Hyoscine hydrobromide Antihistamines - cinnarizine, cyclizine Promethazine,

Answer 369

- Cinnarizine | - cyclizine

Answer 370

- Promethazine

Answer 371

Domperidone, metoclopramide hydrochloride, 5HT3-receptor antagonists, and the phenothiazines (except promethazine—an antihistamine phenothiazine) are ineffective in motion sickness.

Answer 372

An ear, nose and throat (ENT) specialist to confirm the diagnosis.

Answer 373

Betahistine

Answer 374

Should only be prescribed for short term use (up to 5 days)

Answer 375

small increased risk of cleft lip and/or cleft palate in babies born to women who used ondansetron during the first trimester.

Answer 376

Antimuscarinic

Answer 377

Nociceptive pain - which generally responds to treatment with conventional analgesics - Neuropathic pain - responds poorly to conventional analgesics and can be difficult to treat

Answer 378

present for more than 12 weeks (beyond the expected time of wound healing).

Answer 379

Chronic primary pain is defined as pain that has no clear underlying condition, or where the pain (or its impact) appears to be out of proportion to any observable injury or disease.

Answer 380

Types of chronic primary pain include complex regional pain syndrome, fibromyalgia (chronic widespread pain), primary headache and orofacial pain, primary visceral, and primary musculoskeletal pain.

Answer 381

Secondary pain however, is caused by an underlying condition (such as endometriosis, osteoarthritis, rheumatoid arthritis, and ulcerative colitis) and can be organised into 6 pain categories:

Answer 382

cancer-related, neuropathic, post-surgical or post-traumatic, secondary headache or orofacial, secondary musculoskeletal, and secondary visceral.