Central Nervous System Flashcards by Emily Taylor

What are the steps of the pain ladder?

Paracetamol
Paracetamol + Weak opioid
Paracetamol + strong opioid
+/- adjuvants

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What are the main side effects of opioids?

Sedation and anxiolysis, respiratory depression (combination of opioids and alcohol is particularly dangerous)
Cough suppression
pupil constriction
nausea and vomitting
Constipation

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Which kinds of pain are opioids effective on?

acute and cancer pain
effectiveness questionable in chronic non cancer pain
Not effective in neuropathic pain

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What is one of the main issues with opioids

Highly addictive

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What is opioid induced hyperalgesia

Enhanced pain in response to opioid

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What is the first choice regular strong opioid?

Morphine, unless renal impaired

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Why is morphine not indicated in renally impaired patients?

Because of active metabolite accummulation, Chronic kidney disease stage 3-5 or creatinine clearance below 30ml/min should not be used.

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How would you start morphine dosing?

Morphine sulfate MR in two divided doses, rounded to the nearest 10mg. Then add morphine sulfate oral solution 1/6th of the total daily dose every 4 hours as required, rounded to the nearest 5mg

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How can morphine be given in patients with swallowing impairments?

Morphine sulfate modified release capsules can be opened and the contents swallowed without chewing, contents can also be given via PEG tube.

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How should you increase a patients morphine dose?

Remember to include breakthrough dose into the TDD. The new daily dose is the accumulation of these doses over the day. Calculate new breakthrough dose 1/6th of TDD and round to nearest 5mg.

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What are NSAIDs

drugs that act to relieve inflammation but are not structurally related to corticosteroids. They are analgesics, antipyretics and anti-inflammatory drugs.

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What are the common adverse effects of NSAIDs?

Platelet dysfunction, inhibition of COX1, gastritis and peptic ulceration, acute renal failure, sodium and water retention and oedema, analgesic neuropathy, prolongation of gestation and inhibition of labour, hypersensitivity

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How does paracetamol work?

inhibition of prostaglandins

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How are anticonvulsants/anti-epileptics used for pain relief?

carbamazepine, tricyclic antidepressants. Follow neuropathic pain ladder

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Discuss the use of paracetamol at step 1 of the pain ladder

Generally safe at therapeutic doses up to 4g per day in adults orally.
Risk factors for hepatotoxicity: low body weight, elderly/frail, cardiac pulmonary or renal insufficiency, malnourished, alcohol misuse disorder, hep c. If eGFR less than 30ml/min/1.73m2 dose interval minimum of 6 hours. IV dose is weight adjusted

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Discuss the use of NSAIDs for pain

CV/GI, Renal dysfunction risks. Assess risk vs benefit, use for shortest time possible, be aware of adverse effects, gi protection.
Small increased risk of thrombotic events, greater risk at higher doses and long term. Lower risk with naproxen or ibuprofen at low dose
Diclofenac: contraindicated in ischemic heart disease, peripheral arterial disease, cerebrovascular disease, congestive heart failure. Risk of GI event higher in older people, avoid a combination of NSAIDs. Can precipitate renal failure, increased risk of with hypovolemia, or concomitant administration with ACE inhibitors, ARB, diuretics

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What are the 3 safe steps for starting an NSAID

3 SAFE STEPS: don’t use unless you have to, consider topical NSAIDs ahead of oral for osteoarthritis, if they have to be used then balance benefits and risks, use a safer drug at lowest effective dose for the shortest period of time, high priority for medications review, consider gastroprotection

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What must be taken into account with codeine/hidryocodeine?

They have a ceiling effect

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When should tramadol be prescribed?

Only if first line weak opioids arent tolerated as it interacts with other medications, can lead to low seizure threshold

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What non-pharmacological statergies can be used for pain management?

Psychological based therapies, CBT, physical therapy, exercise, electrotherapy, accupuncture

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Describe migraine

can have triggers, presents with aura, and one sided pain in the head usually.

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Discuss management of migraines

Reduction of triggers, keep a headache diary, review medications that may cause headache, pharmaceutical treatments

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What medications can exacerbate migraines?

Oral contraceptive, HRT, medication overuse

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What pharmaceutical treatment can be offered for migraine?

simple analgesia, triptan + paracetamol or NSAID, or anti emetic if needed

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What counselling points go alongside migraine therapy?

Advise that: • Aim is to reduce frequency and severity of migraine symptoms, not complete remission or cure of migraine • Acute treatment and avoidance of know triggers and lifestyle modification will still be required • Consider pharmacological therapies such as propranolol, topiramate, amitriptyline, do not offer gabapentin

Which medications are used for the treatment of schizophrenia?

Chlorpromazine, haloperidol, pimozide, sulpride, trifluoperazine

Discuss clozapine related to schizophrenia

it is the main drug used for schizophrenia, has low extra-pyramidal symptoms, does not increase prolactin, causes sedation and weight gain but no movement disorders

What are the main side effects of clozapine

sedation and weight gain, blood dyscrasia, constipation, drooling

does clozapine cause blood dyscrasia

yes, it starts to attack cells in the bone marrow, and creates damaged blood cells leading to a dip in immunity

is clozapine smoking sensitive?

Yes, the dosage must be adjusted alongside smoking regime

What can be done if the patient experiences drooling with clozapine

Apply a hyoscine patch

What can clozapine be switched to if patients wish to get pregnant?

Haloperidol

What are the main side effects of risperidone

weight gain, EPS, lactation

What are the main side effects of olanzapine

sedation, weight gain, EPS

What can be done if risperidone causes elevated prolactin

change it to olanzapine

What monitoring is required with olanzapine?

It can interact with ciprofloxacin, cause weight gain and predispose diabetes, therefore baseline weight lipids and glucose levels should be taken

Why are SSRIs first choice for depression?

they are cheap, well tolerated, effective, safe in deliberate overdoses

how can you change SSRI?

taper down dose, before titrating up now medication

How is levodopa dosed?

lowest effective, has side effects of nausea and vomitting, which should be treated with domperidone

What is the purpose of modified release levodopa?

To avoid the motor complications associated with short duration of action

What should happen if dopamine agonists cause obsessive activities?

reduce dose of dompamine agonists

What should happen if parkinsons medication needs to be changed?

They should never be stopped abruptly.

How do you calculate pack years?

multiply the number of cigarettes smoked per day by the number of years the person has smoked

How should treatment of epilepsy be started?

low dose titration

What counselling points should be given to patients being started on anti-epileptics?

Levels can be affected by other medications, they should maintain a balanced diet and avoid excessive alcohol intake

What are the main pharmacokinetic interactinos with phenytoin/carbemazepine/phenobarbital?

Induction of metabolism of other anticonvulsants, warfarin, oral contraceptives

What are main counselling points for valproate

it is a good drug for most epilepsy, but disaster for child bearing women. It is a broad enzyme inhibitor associated with the increased concentration of other drugs. Can be affected by oral contraceptive

What are the main points to remember about carbemazepine?

it is used for complex, partial and generalised seizures, has a narrow therapeutic window, short half life

What are the main points to remember for phenytoin

Prescribed for partial or generalised seizure, narrow therapeutic window. must be monitored

What are the main points to remember for lamotrigine?

Lower doses required with sodium valproate, can cause steven-johnson syndrome. Slow titration over a few weeks required

What are key warnings with paracetamol?

In overdose, paracetamol can cause liver failure

When should the paracetamol dose be reduced?

In chronic excessive alcohol use, malnutrition, severe hepatic impairment, low body weight

Are there any important interactions with paracetamol?

CYP inducers such as phenytoin and carbamazepine

What counselling points should go with paracetamol?

Effects should be felt within 30 mins of taking dose, do not exceed maximum dose, take every 4 hours. No more than 8 tablets in a 24 hour period

When should NSAIDs be avoided?

severe renal impairment, heart failure, liver failure, NSAID hypersensitivity

What should be done if NSAID use is unavoidable in high risk patients?

Use safest NSAID at lowest effective dose for the shortest period of time

What should always be considered for patients being prescribed NSAID?

Gastroprotection - PPI

What are the main warnings with morphine?

doses should be reduced in hepatic failure, renal impairment, and elderly. Do not give in respiratory failure

What are key interactions with morphine?

Should ideally not be used with other sedating drugs such as antipsychotics, benzodiazepines, tricyclic antidepressants

How should you counsel a patient around morphine?

- counsel patient not to be worried about the stigma - warn patients that dose may need to be increased/decreased and not to be alarmed - explain how to take - sickness (give metoclopramide) - constipation (senna and good hydration) - do not operate heavy machinery if drowsy