Central Nervous System Flashcards
(241 cards)
1
Q
Dementia
A
Progressive and largely irreversible syndrome characterised by impairment of mental function
Alzheimer’s disease accounts for most cases of dementia
Characterised by a range of cognitive and behavioural symptoms
2
Q
Aims of dementia treatment
A
Promote independence
Maintain function
Manage symptoms of dementia
3
Q
Symptoms of dementia
A
Cognitive dysfunction; memory loss, concentration, communication, problem/reasoning solving
Non-cognitive symptoms below;
Behavioural symptoms; aggression, distress, agitation and psychosis
Difficulties with activities of daily living e.g washing or dressing
4
Q
Non-drug treatment of dementia
A
Structural cognitive stimulation programme to patients with all types of dementia presenting with cognitive symptoms = to stimulate the mind
5
Q
Types of dementia
A
- Protein build up; decreases ACh causing dementia; treated by stopping ACh decline
- Vascular dementia; reduced blood flow to brain; treat similar to stroke and cognitive rehabilitation
6
Q
What drug class to avoid in dementia?
A
Anticholinergics
E.g antidepressants, antihistamines, antipsychotics
As they further increase decline of Ach
TREAT DEMENTIA WITH ACETYLCHOLINESTERASE - therefore anticholinergics do the opposite
7
Q
Mild to moderate dementia drugs used?
A
Anticholinesterase inhibitors
Donepezil - neuroleptic malignant syndrome; increase risk with concomitant antipsychotic
Galantamine - stop if rash appears SJS
Rivastigmine - GI disturbances (withhold until resolved can switch to patches)
8
Q
Moderate to severe dementia drug treatment
A
Memantine
NMDA glutamate receptor antagonist
Anti-cholinesterase is CI in moderate or severe Alzheimer’s
9
Q
Anticholinergic side effects
A
Diarrhoea
Urination
Muscle weakness or cramps
Bronchospasm
Bradycardia
Euresis
Lacrimation
Salvation or sweat
10
Q
MHRA warning with dementia and elderly patients
A
Antipsychotics should only be offered if risk of harming themselves or others; experiencing, agitation, hallucination, delusion which is causing severe distress
Causes increase risk of stroke and death
Risk vs benefit
Need to closely monitor
11
Q
Dementia and co-morbidities
A
Depression and anxiety; use antidepressants for pre-existing severe MH problems due to anticholinergic effect
Agitation, agression, distress and psychosis
Sleep disturbances; ideal mainstay of treatment would be to use non-drug interventions to avoid mental cloudiness and sedation
12
Q
Management of cognitive symptoms in dementia
A
Should be initiated by specialists
Reassess treatment for; donepezil, galantamine, rivastigmine and mementine regularly
Only continue treatment if symptoms are improving
Avoid antipsychotics unless you have to
Avoid anticholinergics id possible
13
Q
Epilepsy control
A
Treatment aims to prevent occurrence of seizures
Start small doses and increase gradually until seizures are controlled
Choice of epileptic drug determined by several factors; Comorbidity, concomitant medication, age, sex and epilepsy syndrome
Keep dosage frequency as low as possible to encourage patient adherence
14
Q
Once daily antiepileptics
A
Good for compliance
Lamotrigine, Perampanel, Phenobarbital and Phenytoin
LP3
15
Q
Epilepsy management
A
1st line is monotherapy; one drug used
2nd line addition of second drug (CAUTION; when changing and adding as withdrawal can cause rebound seizures
Combination therapy with 2/+ can increase S/E and drug interaction
Stick to regime that provided best balance between tolerability and efficacy
Prescribe a single anti epileptic drug wherever possible
16
Q
MHRA advise on epileptic drugs
A
Potential harm between switching between brands / generic products
3 risk category to help HCP decide what to switch or not
Switching between formulations - can lead to variety in bioavailability hence should remain on specific manufacturers products
17
Q
Category 1 anti epileptics
A
SPECIFIC BRAND - if being used for anti epileptic purposes
Report any adverse effects suspected on yellow card system
Carbamazepine, phenytoin, phenobarbital and primidone
CP3
18
Q
Category 2 anti-epileptic drugs
A
Need for continuing on same brand depends on clinical judgement and consultation with the parent/carer
E.g valproate, lamotrigine, clobazam and clonazepam
19
Q
Category 3 anti-epileptic drugs
A
No need for maintenance on specific brand except concerns for patient anxiety, risk of confusion or dosing errors. consult patient
E.g levetiracetam, gabapentin, pregabalin, vigabatrine, ethosuximide
20
Q
Carbamazepine
A
Tegretol or Carbagen (restard or IR)
High risk drug
Must prescribe and maintain on specific brand if being used for epileptic control
Risk congenital malformation in pregnancy
Risk suicidal thoughts and behaviours
Risk SJS in presence HLA-B*1502 allele
Is an enzyme inducer
Used focal and secondary/primary generalised tonic-clinic seizures, prophylaxis of bipolar disorder
21
Q
Carbamezapine range
A
4 - 12 mg/L
22
Q
Carbamezapine side effects
A
Blood dyscarsia
Hepatoxicity
Rash
HYPOnatraemia
Thrombocytopenia
Nausea, vomiting, sedation, dizziness and ataxia; dose related most common at start of treatment
23
Q
Carbamazepine monitoring
A
Serum carbamazepine levels not routinely monitored unless toxicity is suspected
FBC and LFTs should ideally be checked before starting treatment, and periodically thereafter
24
Q
Carbamezapine toxicity
A
HYPOnatraemia
Ataxia
Nystagmus
Drowsiness
Blurred vision
Arryhtmias
GI
25
Contraindication and cautions in carbamazepine
History of bone-marrow depression
Stop treatment if leukopenia develops
Withdraw immediately in case of aggravated liver dysfunction or acute liver disease
26
Carbamezapine patient and carer advise
Report signs of blood, liver or skin disorder
Immediate medical attention fever, mouth ulcers, bruising or bleeding develop
Report any distressing thoughts or feelings about suicide or self-harm
27
Carbamazepine interactions
DOACs and warfarin
Macrolide
COC and POC
Phenytoin
Ciclosporin
Diltiazem, verapamil
Ticagrelor
28
Phenytoin
Tonic-clinic seizures, focal seizures and status epilepticus
AVOID in absence/ myoclonus as it exacerbates
Maintain on a specific brand
Risk suicidal behaviour and congenital malformation in pregnancy
Zero order clearance
Risk SJS with HLA-B1502* positive
Enzyme inducer
Acts as a anti-folate, highly protein bound drug increase blood dyscarsia
29
Phenytoin adverse effects
Gingival hyperplasia
Agranulocytosis
Thrombocytopenia
Altered taste
Change in facial appearance
Symptoms; toxicity are nystagmus, diplopia, slurred speech, ataxia, confusion and hyperglycaemia
30
Phenytoin monitoring
10-20 mg/L are optimum levels
Narrow therapeutic index
Small change in dosing can result in a large change in blood levels
31
Contraindication and cautions with phenytoin
Acute porphyria
Avoid HLA-B1502* positive allele
Sinus bradycardia
Second and third degree heart block
32
Patient and carer advice on phenytoin
Reports signs of blood or skin disorders
Seek immediate medication attention if symptonms; such as fever, rash mouth, ulcers, bruising or bleeding develop.
Report signs distressing thoughts or feelings about suicide or self-harm
33
Phenytoin interactions
COC, St John’s wart and warfarin decrease phenytoin concentration = therapeutic failure
Cimetidine, fluoxetine and TCA = increase concentration of phenytoin
Anticonvulsant effect antagonised with quinolones, SSRIs and TCAs as it reduced threshold of seizure
Hepatoxicity risk increased with tetracyclines, sulfazalazine, methotrexate and statins
POP,COC, valproate, DOAC, amiodarone
34
Phenobarbital
Status epilepticus and ALL forms of epilepsy EXCEPT typical absence seizures
Maintain on specific brand
Risk suicidal thoughts and behaviours
Risk congenital malformations
Avoid abrupt withdrawal as dependence may develop with prolonged us
Schedule 3 drug
Risk SJS
35
Phenobarbital patient and carer advise
Dispensed and collected within 28 days of appropriate date
Consider Vitamin D supplementation if immobilised or have inadequate sun exposure or dietary intake of calcium
36
Adverse effects of phenobarbital
Anxiety
Hallucination
Hypotension
Megaloblastic anaemia
Thrombocytopenia
Skin reactions
Folate deficiency
Known to induce hepatic cytochrome P450 enzymes
37
Phenobarbital and monitoring
Optimum plasma levels 15-20 mg/L
38
Contraindication and cautions with phenobarbital
Avoid in acute porphyrias
Children
Debilitated
elderly
Hx of alcohol and drug abuse
Cross sensitivity reported with carbamazepine
39
Anti-epileptic hypersensitivity syndrome
Rare but potentially fatal syndrome associated with some epileptic drugs e.g carbamezapine, phenytoin, phenobarbital, primidone, lamotrigine
Symptoms start between 1 to 8 weeks of exposure
Most common symptoms; fever, rash, liver dysfunction, renal and pulmonary abnormalities and multi organ failure
STOP IMMEDIATELY IF ANY OCCUR OR IS SUSPECTED
40
MHRA warning for anti epileptics
ALL associated with small increased risk of suicidal thoughts and behaviours
Symptoms occur 1 week after starting medication
Refer to Dr if changes in; mood, distressing thoughts, feelings about suicide or self harm
41
Anti-epileptic and it’s withdrawal
Withdraw under specialist supervision
Not to withdraw abruptly, can precipitate severe rebound seizures
Reduce dose gradually; barbiturates may take months
Withdraw only one drug at a time for patients receiving more than one drug
42
Epilepsy and driving
Inform DVLA when you have a seizure
First unprovoked epileptic seizure OR single isolated seizure must not drive for 6 months
To continue driving patient must be seizure free for at least a year and must not have a history of unprovoked seizure
Must not drive during medication changes or withdrawal of anti epileptic drug and for 6 months after their last dose - if seizure occurs from change or withdrawal = license revoked for 1 year or 5 year ban on large vehicle goods
43
Pregnancy and antiepileptics
Increased risk of teratogenicity especially during the 1st trimester and if take 2/+ anti-epileptics
Caution as they can decrease efficacy of hormonal contraception
Sodium valproate is associated with the highest risk of serious developmental disorders and congenital malformations - not to be used in female of child bearing age unless on PPP and no alternative
Topiramate can cause cleft palate in the 1st trimester; monitor foetal growth
Vitamin K injections in newborns minimise risk of neonatal haemorrhage
5mg folic acid recommended in first 12 weeks
44
Sodium valproate
Indicated in ALL forms of epilepsy
Highly teratogenic
PPP for those of child bearing potential and no alternative
Liver toxicity can occur especially in children under 3; bruising, jaundice, itchy skin or dark urine
Can affect clotting; discontinue if prolonged prothrombin time
Can cause pancreatitis - discontinue if this occurs
45
Pregnancy Prevention Plan (PPP)
Annual review of existing patients
At least one highly effective method of contraception or 2 complementary forms contraception including barrier
46
Vigabatrin
Visual disturbances
Causes encephalopathic symptoms; stupor, marked sedation, confusion
Visual defects persist even after stopping drug
Test before treatment and at 6 month intervals
Report any signs visual urgently
47
Status epilepticus
2 types; convulsive and non-convulsive status epilepticus
48
Convulsive status epilepticus
Is a convulsive seizure which continues for a prolonged period >5 minutes or when convulsive seizure occurs one after the other with no recovery in between
EMERGENCY REQUIRED IMMEDIATE MEDICAL ATTENTION
Treat; IV Lorzepam avoid IV diazepam as its thrombophlebitis
49
Non convulsive status epilepticus
Status epilepticus is less common and less urgent
50
What is febrile convulsion
Seizures in children who have high fever
If they last longer than 5 mins treat as status epilepticus
51
Convulsive status epilepticus management
Position patient to avoid injury, support respiration including providing oxygen
Maintain blood pressure and correct any hypoglycaemia
Give parenteral thiamine if alcohol abuse suspected
Give pyridoxine if caused by pyridoxine deficiency; B6 deficiency
Seizure lasting >5 minutes is urgent treat with IV lorazepam
If seizure continues give phenytoin sodium or fosphenytoin (fewer s/e, severe cardio reactions, prodrug phenytoin)
Monitor for respiratory depression and hypotension
52
Generalised tonic-clinic seizure
Sodium valproate as first line monotherapy; men, girls under 10 and women who cant have children
Offer lamotrigine or levetiracetam as first line in women of childbearing, 13+ or above not appropriate
Others are add on treatment if above fails such as clobazam, lamotridge, topiramate
53
Absence seizure
Ethosuximide as first line treatment for absence seizures
If first line unsuccessful offer sodium valproate as second-line monotherapy
Third line would be; lamotrigine or levetiracetam; off-label if under 2
54
Myoclonic seizures
Sodium valproate is first line treatment
Levetiracetam as first line treatment for myoclonic seizure in women and girl able who can have children offlabel if under 12
55
Tonic or a clonic seizures
Ensure assessed and diagnosed by neurologist
First line —-> sodium valproate
Second line ——> lamotrigine or levetiracetam
1st line adjuncts - clobazam, lamotrigine, levetiracetam, perampanel, na valproate
2nd line adjuvants - brivataceyam, lacosamide, phenobarbital. Primidone,
56
Anxiety
Psychological symptoms; restlessness, worry, fear, sleep disturbance, irritable on edge
Physical; palpitations, muscle ache, trembling, SOB, insomnia, muscle tension,
GAD-7 questionnaire for diagnostic tool
57
Benzodiazepines
CD4 part 1
Long acting; diazepam,, clonazapam, chlorazepoxide
Short acting; lorazepam, temazepam, oxeazepam
Used anxiety or other muscle spasm, epilepsy, alcohol withdrawals etc
Use short term to treat anxiety (2-4 weeks)
Short acting used in elderly, liver impairment, short term e.g dentist
58
Benzodiazepine cautions
Avoid in prolonged use = dependence
Avoid abrupt withdrawal; as it has strong withdrawal effects anxiety, weight loss, tremor, loss appetite
Pts with hx of drug or alcohol dependence
Paradoxical effects; increase hostility and aggression, range from being talkative to aggressive, increase anxiety and perceptual disorders; adjusting doses can diminish these symptoms
59
Benzodiazepine side effects
Decreased alertness
Anxiety
Ataxia and confusion
Dizziness and drowsiness
Fatigue
GI disorders, sleep disorders
Tremor
Suicidal thoughts
60
Contra indications for benzodiazepines
Acute pulmonary insufficiency
Unstable myasthenia gravies
Sleep apnoea syndrome
61
Benzodiazepine patient and carer advice
Effects are enhanced with alcohol; increased sedation or depressant effect
Drowsiness may persist next day and affect performance
Give at night for insomnia
62
Pregnancy / breastfeeding and use of benzodiazepines
Risk of neonatal withdrawal symptoms when used during pregnancy
Avoid regular use and only use if there’s clear indication
Neonatal hypothermia and respiratory deppresion = high doses in labour or late pregnancy
Present in breast milk so avoid unless necessary
63
Hepatic impairment and benzodiazepines
Can precipitate coma
Give shorter half life if necessary
Avoid in severe impairment
64
Short acting benzodiazepines
ATOM
Alprazolam
Temazepam
Oxazepam
Midazolam
No residual effect, less drowsiness next day etc
65
Benzodiazepines withdrawal
Withdraw over 1 week
Decrease in increments and small steps
66
What other drugs are used in anxiety?
Beta blockers; e.g propranolol for autonomic symptoms such as propranolol
Buspirone 5HT1A agonist; less risk of abuse
Antidepressants
67
Attention deficit hyperactivity disorder ADHD
Hyperactivity, impulsivity and Inattention - lead to social, educational or occupational impairment
Co-exist symptoms
Typically appear children in 3-7 years but not recognised till later
Must be managed to prevent; as children can grow up with adulthood difficulties which can lead to social difficulties, substance misuse, personality disorder etc
68
Aims of ADHD treatment
Reduce functional impairment and severity of symptoms
Improve quality of life
69
ADHD drug treatment
1st line is methylphenidate OR Lisdexamfetamine mesilate
If symptoms don’t improve after 6 week trial switch to alternative first line
Dexamfetamine sulfate (unliecensed) if patients have positive benefits with Lisdexamfetamine but cant cope with its longer duration of effect
2nd line Consider atomexetine after the above
70
Non-drug treatment for ADHD
Balanced diet
Good nutrition
Regular exercise
Environmental modifications; e.g noise reduction seating, more breaks
CBT
71
Atomoxetine
Works better in drug misuse patients
Monitor; sleep pattern, sexual dysfunction, stimulant diversion or misuse, appetite, weight loss, suicidal thoughts
Cause; QT prolongation, hepatoxicity, suicidal idealisations
120 mg max in adults and 100 in children
72
Methylphenidate
CD2
Concerta XL, Equasym CL, Medikinet XL, Xaggitin XL
Not for under 6, unliecensed over 60 mg or over 54 in concerta
MHRA alert; caution when switching brands
Monitor for psychiatric parameters, bp, pulse, weight
S/e; growth restriction in children, insomnia, increase HR/BP, agression, anxiety, depression
Caution; dysphagia, alcohol dependence, anxiety
CI; arrhythmias, cardiomyopathy, CVD, HF, mania
73
Lisdexamfetamine mesilate
CD2
Elvanse
Caution; bipolar disorder, hx CVD, hx substance abuse, may lower seizure threshold, caution in underlying compromised can increase BP or HR
CI; agitated states, hyperthyroidism, hypertention, symptomatic CVD
S/e; abdominal pain, anxiety, appetite decreased, dry mouth
Monitor for signs aggressive behaviour or hostility during treatment, BP, pulse
74
Bipolar disorder and mania
Serious long term
Chronic conditions with periods of lows and highs
Mania lasts for more than 7 days or hypomania for more than 4 days
75
Symptoms of mania
Grand ideas and self importance to oneself
Increased energy and less sleep
More talkative than usual
Full of new ideas and plans; often big and unrealistic
Irritation or agitation
Pleasurable activities in excess; spending money, alcohol, drugs, sexual
Accompanied by psychotic symptoms; delusions or hallucinations, flight of ideas racing
Hypomania is high but not as severe
76
Symptoms of depression in bipolar disorder
Low mood for most of the day,
Loss of enjoyment and interest in life of activities normally would enjoy
Abnormal sadness, often with weepiness
Feeling guilty worthless or useless
Poor motivation and difficulty in concentrating
Sleeping problems
77
Medication to treat bipolar disorder
Benzodiazepines and antipsychotics for acute episodes of mania
Carbamazepine for rapid cycling or unresponsivness to other treatment
Lithium
78
Mania and hypomania drug treatment
Control acute attacks and prevent recurrent episodes
Continue long term treatment of bipolar for at least 2 years from last manic episode and up to 5 years if patient has risk of relapse
Benzodiazepines; e.g lorazepam for agitation/behaviour disturbance, avoid in long term use =dependence
Antipsychotics; olanzapine, quietipine, risperidone
Carbamazepine; can be used for rapid cycling bipolar
Lithium
79
What drug would you avoid in rapid cycling bipolar disorder
Antidepressants
They will precipitate mania episodes
80
Lithium
Gold standard; used for prophylaxis and treatment of mania, bipolar disorder, recurrent depression
Full prophylactic effect may not occur for 6-12 months after initiation
High risk drug carry lithium card
Prescribe by brand
81
Lithium contraindications
Dehydration; increases lithium levels
Low sodium diet or levels; increases lithium levels
Addisons disease; lithium block fludrocortisone action
Cardiac disease as it effects electrolyte balances
Untreated hypothyroidism (as lithium can cause hypo)
82
Cautions with lithium
Avoid abrupt withdrawal
Diuretic treatment increase toxicity
Lowers threshold of seizure
QT prolongation
Review doses elderly, diarrhoea, vomiting, surgery and inter current infections
Thyroid disease in long term; monitor every 6 months TSH
83
Lithium side effects
Increased urination
Thirst
Hypothyrodism
Muscle weakness
Skin effects
Angioedema
Abdominal discomfort
Arrhythmias
Memory loss, tremors, vertigo, electrolyte imbalance
84
Signs of lithium toxicity
Nausea and vomiting
Fine tremor
CNS disturbances; confusion, drowsiness, lack of coordination
AV block
Visual disturbances
85
Lithium monitoring
Weekly Lithium levels after initiation until stable then every 3 months for 1st year then every 6 months thereafter (some pts may require 3 months)
Monitor; ABW/BMI, U&Es, EGFR and TFTs every 6 months
Cardiac, thyroid, renal, FBC and BMI before treatment
86
Lithium advice
Avoid dietary changes which increase sodium intake
Maintain adequate fluid intake especially when ill as there’s risk of dehydration
87
Lithium withdrawal
Abrupt discontinuation increases risk of relapse
Reduce gradually over a period of at least 4 weeks to 3 months
If stopped or discontinued abruptly consider changing therapy to atypical antipsychotic or valproate
88
Lithium and breastfeeding
Avoid
Present in milk
Risk of toxicity in infants
89
Lithium and pregnancy
Avoid if possible especially in 1st trimester risk of teratogenicity include cardiac abnormalities
Dose requirements increase during 2nd and 3rd trimester but return to normal on delivery
90
Lithium levels
0.4 - 1 mmol/L for maintenance and elderly
0.8 - 1 mmol/L for acute episodes of mania and patients who previously relapsed
91
Drug interactions and lithium
Increase Li concentration; ACEi/ARBs, diuretics, NSAIDs, metronidazole, amiodarones and tetracyclines
Decreased Li concentrations sodium containing antacids, theophylline
Drugs that increase QT prolongation or seizure or cause HYPOkalaemia
Increase neurotoxicity with; SSRIs, antipsychotics, carbamezapine, Triptans
92
Sodium levels and lithium
Low sodium = high lithium
High sodium = low lithium
93
Depression
Psychological; low self-esteem, worry/anxiety, suicidal thoughts, worthlessness, low mood, suicidal
Physical; lack of energy, change weight or appetite, insomnia
Diangnosel DSM-5 criteria, PHQ-9, HADS
94
3 major classes of antidepressants
Tricyclic and related depressants
Selective serotonin reuptake inhibitors
Monamine oxidase inhibitors
95
Antidepressants
Effective for moderate to severe depression
Not for mild as psychological therapy is preffered
Improvement in sleep usually 1st benefit of drug therapy
Increased potential for agitation, anxiety and suicidal thoughts during first few weeks of treatment
All classes have similar efficacy but different side effect profile
2-4 weeks for full effect
96
What is the first line treatment for depression
1st line is SSRIs; Better tolerated , Safer in overdose, Less sedating and Fewer antimuscarinic and cardio toxic effect
TCAs are similar to SSRis but more s/e, dangerous in overdose, more sedating and antimuscarinic and cardio toxic s.e
MOAis are specialist use and have dangerous interactions with drugs and food
97
St John’s Wart
Hypericum perforatum
Herbal remedy
Used to treat mild depression
Don’t prescribe or recommend for depression; big enzyme inhibior / inducer interacts a lot
Different preparations have different amount of active ingredients
98
Antidepressant management
Review patients every 1-2 weeks at the start of treatment
Continue treatment for at least 4 weeks (6 weeks for elderly) before switching due to lack of efficacy
In case of partial response continue for further 2-4 weeks (elderly may take longer to respond)
Continue 6 months or after remission,, patients with history of recurrent depression should receive maintenance treatment for at least 2 years
99
Biggest side effect for all antidepressants
Hyponatraemia
Salt loss in all types of antidepressants more common in SSRIs
Dangerous with Lithium toxicity
100
Symptoms of hyponatraemia
Stupor/coma
Anorexia
Lethargy
Tendon reflexes
Limp muscles
Orthostatic hypotension
Headaches
Stomach cramps
101
Suicidal behaviour and antidepressants
Linked with antidepressant use
Children, young adults and individuals with history suicidal behaviour are particularly at risk
Monitor patients for suicidal behaviour, self-harm,, hospitality especially at beginning of treatment or if dose changes
102
Serotonin syndrome
Risk is greater during addition of antidepressant and when cross-tapering
Symptoms can occur days/hours after initiation, dose increase or overdose or tapering
103
Serotonin syndrome symptoms
Autonomic; increase heart rate and blood pressure
Neuromuscular; tremor and ridigity, tremor, shivering,
Mental state; mania, confusion and agitation
104
Antidepressant 1st line failure what to do
Increase the dose or switch to different SSRIs or mirtazepine if initial response to SSRI fail
Second line choices include lofepramine, moclobemide and reboxetine
Venlaflazine SNRI reserved for more severe cases
MAOI requires specialist supervision
3rd line add another antidepressant class
105
TCA classes
Divided into
Sedating; for agitated and anxious patients; amitritiline, clompiramine, donsulepin, trazodone
Less sedating; for withdrawn and apathetic patients e.g imipramine, lofepramine, nortriptyline
106
Contra-indications for TCAs
Manic phase in bipolar
Arrhythmias
Heart block
Immediate recovery period after MI
Mainly CV related conditions
107
Cautions with TCCAs
CV disease
Diabeties
Chronic constipation
Epilepsy
Hx of bipolar psychosis; increases mania
Hyperthyroidism (risk of arrhythmias)
Glaucoma urinary retention
Stop is patients enter manic phase of bipolar
Elderly patients more susceptible to side effects; give low doses and monitor
108
Common side effects TCAs
Anticholinergic; Anorexia, blurry vision, constipation, confusion, dry mouth, static urine
Drowsiness
QT interval prolongation; cardiac s.e, higher risk clompramine
109
Overdose in TCAs
Toxic
Dry mouth, coma, hypotension, hypothermia, arrhythmias, urinary retention dilated pupils
Lofepramine; less s/e and less dangerous in overdosage but associated with hepatotoxicity
Amitriptyline and donsulepin most dangerous in overdose
110
Common TCAs interactions
Lithium increases risk of neurotoxicity
Increase risk of toxicity when given with MAOIs
Avoid for 2 weeks after stopping MAOI
Risk HYPOnatraemia , hypotension, antimuscarinic effects, serotonin syndrome
111
Monoamine-oxidase inhibitors
Irreversible; isocaboxazid, phenelzine, tranylcpromine
Reversible; moclobemide
112
MAOI and interactions
Life threatening hypertensive crisis with tyramine rich food such as mature cheese, food going off, alcohol, yeast extract. TYRAMINE EFFECT
Risk continues for 2 weeks after stopping too
Sympathomimetics e.g cold + flu remedies e.g decongestants = hypertensive crisis
Interactions can cause hypertension / throbbing headaches
113
MAOI and withdrawal symptoms
Avoid abrupt withdrawal
Agitation, irritability, ataxia, movement disorders, insomnia, vivid dreams
Hallucinations, slowed speech, delusions
Risk of symptoms increased if stopping suddenly after regular admin for 8 or more weeks
114
Cautions in MAOI
Hepatotoxicity in patients with hepatic impairment
Increase risk of neonatal malformations when used in pregnancy
S/e risk of postural hypotension and hypertensive responses
Discontinue if palpitations or frequency headaches occur
115
Patient and carer advice in MAOI
Eat only fresh food and avoid stale food or going off
Avoid alcoholic drinks or dealcohlised drinks (low alcohol)
Danger of interactions lasts for 2 weeks after MAOI is discontinued
Drowsiness may affect skilled skills
116
Reversible MAOI
Moclobemide (stronger and expensive) for major depression, social anxiety disorder
Interactions; less tyramine effects than irriversible ones but still avoid tyramine rich foods,
Less risk of drug interact
117
Changing classes of antidepressants; washout phases
From MAOI;
Wait 2 weeks to switch to other classes or other MAOI
Wait 3 weeks to switch to imipramine or clomipramine
TO MAOI;
TCAs wait 1-2 weeks
SSRIs wait 1 week
Fluoxetine wait 5 weeks
Sertraline wait 2 weeks
Clomipramine or imipramine wait 3 weeks
PREVENT SERATONIN SYNDROME
118
SSRI
Citalopram, escitalopram, fluoxetine, paroxetine, sertraline etc
Increases harmful outcomes in children and adolescences; self harmin agitation and suicide risk
119
What is the safest antidepressant in children
Fluoxetine (Prozac)
Most effective and only licensed from 8 years
120
Contra indications of SSRIs
Poorly controlled epilepsy
Mania
Citalopram and escitalopram specific; QT prolongation
121
Caution with SSRIs
CVD
DM; due to weight gain
Epilepsy; discontinue if convulsions develop
Hx of bleeding disorders
Hx or mania
Susceptibility to angle glaucoma
122
SSRIs side effects
Less sedating and fewer antimuscarinic effects than TCAs
Anxiety, arrhythmias, confusion, drowsiness, constipation, QT interval prolongation, dry mouth, skin reactions, nausea, palpitations
HYPOnaraemia
Bleeding risk
Reduced seizure threshold
123
SSRI interactions
NSAIDs; can increase risk of bleeding
Warfarin; severe increase risk of bleeding
Hyponatraemia; with diuretics, NSAIDs, desmopressin
Grapefruit juice can increase plasma concentration
QT prolongation with erythromycin or amiodarone
124
SSRI and pregnancy
Avoid in pregnancy unless benefits outweighs risks
Small risk of congenital heart defects when taken in early pregnancy
3rd trimester risk of neonatal withdrawal symptoms and persistent pulmonary hypertension in newborn
125
Mirtazapine
Used in major depression
S/e; weight gain, confusion, blood dyscrasia
Taken at night
126
SNRIs
For major depression and generalised anxiety disorder
Duloxetine also used diabetic neuropathy and urinary incontinence
Venlaflaxine is CI in uncontrolled hypertension or arrhythmia
S/e; weight loss, abnormal dreams and sexual dysfunction
Venlaflaxine causes QT prolongation, increase cholesterol
127
Antipsychotics
AKA neuroleptics or tranquillisers
Management of schizophrenia, mania, bipolar disorder and severe depression
Short term use but patients may require life long treatment
Aim improve social and cognitive function
128
Symptoms of schizophrenia
Overactivity in Mesolithic pathway;
Positive symptoms; thought disorders, hallucinations and delusions
Under activity in mesocortical pathway;
Negative symptoms; social withdrawal, apathy , self-neglect
Most common psychotic disorder and presents with either hallucination or delusion for 1 month or longer
129
Treatment for schizophrenia
Oral antipsychotics
First and second generation (second gen better for negative symptoms)
CBT or family intervention
130
1st generation antipsychotics
Act predominantly on D2 receptors in the brain
Non-selective cause range of side effects; EPSE and elevated prolactin
Group 1; Chlorpromazine, levopromazine and promazine = more sedative and moderate EPSE/antimuscarinic
Group 2; pericyazine and pipotiazine = moderate sedative and lowest group for EPSE
Group 3; prochloperazine, trifluroperazine, fluphenazine, perpherazine = less sedative most EPSE
Flupentixol (QT prolongation) and zuclopentixol (Depot)mod sedative and antimuscarinic
Haloperidol (QT prolongation) and benpenidol are butylrophenones similar to group 3
131
Prolactin and 1st generation antipsychotics
Main side effect
Elevated prolactin levels
Associated with loss of libido or sexual dysfunction, infertility.
Male specific; decreased ejaculation volume
Female specific; amenorrhea, strophic changed reduced lubrication acne hiritusism
132
2nd generation antipsychotics
Atypical antipsychotics
Have higher affinity for specific D receptors = less s/e
Negative symptoms treated better
Amisulpiride, arirpirazole, clozapine, olanzapine, quiteipine and rispiridone
133
Clozapine
Licensed to pt who fail response to other antipsychotics (tries 2/+ drugs including secondary generation for at least 6-8 weeks)
Leucocyte and blood count weekly for 18 weeks then every 2 weeks for up to 1 year then monthly.
Body weight and blood lipids every 3 months then yearly
Monitor BF after 1 month, then every 4-6 months
Adverse effects; myocarditis (occur within 2 months), agranulocytosis, GI obstruction (MHRA report constipation due to risk) ,hypersaliation
134
When would antipsychotics be deemed ineffective?
No improvement within 4-6 weeks after starting the drug
Prescribing more than 1 antipsychotic risk adverse effects
135
EPSE
Parkinsonism symptoms (tremors; common in elderly or adults)
Acute dystonia
Akasthesia; restlessness unable to stay still
Tardiness dyskinesia; irreversible
Increased prolactin concentration and hyperprolacinaemia affects fertility
Can suppress by giving antimuscarinic
ADAPT
136
What is special about aripiprazole?
2nd generation
With partial agonist effects on DA receptors hence is useful in reducing prolactin
137
Other s/e of antipsychotics?
Decreased libido; rispiridone, haloperidol’s, erectile dysfunction, arousal distorted
Tachycardia, arrhythmias and hypotension QT prolongation; all
Hyperglycaemia, diabetes, weight gain = clozapine, olanzopine, quitiepine
Hypotension= risk falls in elderly, clozapine, quitipine, chlorpromazine
Blood dyscarsia
Hyperprolactinaemia
138
Which antipsychotic to give?
Little difference in efficacy between them all
Choice is based on; med hx, degree of sedation required, risk EPSE, weight gain, impaired glucose tolerance, QT interval presence or negative/positive symptoms
139
Diabeties and antispychotics
Check fasting blood glucose
Schizophrenia is associated with insulin resistance and diabeties
Risk increases if patient is taking antipsychotics and schizophrenia
1st generation have lower risk compared to second generation
140
Weight gain and antipsychotics
Increase weight olanzopine and clonazepine
Avoid as indirectly weight gain linked to diabeties risk and CVD
Drugs that dont affect the weight; amisulpiride, aripirazole, haloperidol sulpiride etc
141
Sexual dysfunction and prolactin in antipsychotics
Aripirazole and quitiepine have lowest risk
142
Stopping antipsychotic treatment
Higher risk of relapse if stopped after 1-2 years
Gradual after long term use
Monitor patient for 2 years after withdrawal for signs of relapse
143
Patient or carer advice for antipsychotics
Photosensitation - avoid direct sunlight
Driving - drowsiness
Alcohol can make above worse
144
DEPOT injections
Long acting (1-4 week)
Used for maintenance for pts with poor compliance
Have more EPSE than oral preps
Zupenthixol prevents relapse
Flupentixol for agitated and aggressive patients
145
Motor neurone disease
Neurodegenerative
Affects brain and spinal cord
Degeneration of motor neurones leads to muscle weakness, muscle cramps, wasting and stiffness, loss of dexterity, reduced respiratory and cognitive function
Refer all patients to neurologist without delay
146
Aims of treatment for motor neurone disease
No cure; progressive disease
Treatment focuses on monitoring functional ability and managing symptoms
Non-drug treatment nutrition, psychological support, physio, exercise, use of mobility aids etx
147
Symptom management of motor neurone disease
Quinine is 1st line for muscle cramps
2nd line baclofen cramps and stiffness avoid abrupt withdrawals
Tizanidine cramps and stiffness
148
Parkinson’s disease
Progressive neurodegenerative condition
Results from death of dopamine cells of substantial in niagra in brain
Present with;
Motor symptoms; hypokinesia, bradykinesia, ridgidity, rest tremor
Non-motor; dementia, depression, sleep disturbance, bladder and bowel dysfunction, speech/language, swallowing problems, weight loss
Inform DVLA and car insurance once diagnosis is confirmed
Refer patients to a specialist and review every 6-12 months
149
Aims of treatment for Parkinson’s disease
Incurable disease
Control symptoms
Improve quality of life
150
Non drug treatment for Parkinson disease
Physiotherapy
Speech and language therapy
Occupational therapy
Dietician
151
What drugs should be avoided in Parkinson disease?
Anti-dopamine drugs
As PDs is treated with dopaminergics to increase dopamine
152
Management of motor symptoms in Parkinson disease
If QoL is AFFECTED; levodopa +carbidopa (co-caraldopa) OR co-benaldopa
If QoL is NOT affected; levodopa, non ergot derived dopamine receptor agonists or monoamine oxidise B inhibitors
153
Dopaminergic drugs used in Parkinson disease
Catecotol-o-methyltransferase inhibitors (entacapone, opicapone, tolcapone)
Dopamine precursors (co-beneldopa, co-careldopa) associated more motor complications
Dopamine receptor agonists (amantadine, pramipexole, apomorphome, ropinolol) mimics dopamine actions s/e fibrotic reactions, hallucinations and sweats
Monoamine-oxidase B inhibitors (rasagiline, selegiline , safinamide) prevents degradation of dopamine, interactions with OTC decongestant to cause hypertensive crisis
154
Selegiline
Metabolised into amfetamine which is driving offence
155
Levodopa
Is a AA precursor for dopamine
Need to take at a specific time of day
1st line in parkinson disease
To avoid ‘off’ period
Weakness or restricted mobility
End of dose deterioration with shorter length of benefit - give MR preparations
Given with dopa decarboxylase inhibitor to reduce peripheral conversation of levodopa; decrease side effects
156
‘End of dose’ and PD drugs
Use COMPT inhibitors
Entacapone and tolrapone
Prevents peripheral breakdown levodopa so more reaches the brain
As PD progresses there is less dopamine in the brain so more meds are needed to make up for the lack of dopamine being produced
157
Adjuvant therapy in Parkinson disease
For patients who develop dyskinesia or motor fluctuations despite optimal levodopa
ADD pramipexole, ropinirol, rotigotine, rasaligine, selegiline, entacapone, or rolcapone
Choices for; non-ergot derived, MAO-B inhibitors or COMPT inhibitors
158
Management of non-motor symptoms
Daytime sleepiness and sudden onset of sleep; modafinil; advice not to drive
Nocturnal akinesia; levodopa or oral dopamine receptor agonis 1st line or 2nd line rotigotine
Postural hypotension; midodine Hcl 1st line and fludrocortisone 2nd
Depression
Psychotics; hallucinations and delusions, queitipine unlisenced
Rapid eye movement sleep disorder; rule out other causes
Drooling saliva; speech language therapy, Glycopyrronium bromide 1st line unlicensed them botulinum toxin type A as second line
Parkinson disease dementia; cholinesterase inhibitor rivastgmine (only) memantine unliesenced
159
What to do in advanced Parkinson’s disease
D-mine pump used
Give apomorphine injection s/c; use refractory motor fluctuation ‘off’ episodes
S/e is nausea and vomiting often use domperidone (but together cause serious arrhythmias risk) 2 days before then discontinue
Causes QT interval prolongation
160
Impulse control disorders and PD
Side effect of increase in dopamine
Causes compulsive gambling, hyper sexuality, binge eating obsessive shopping
Higher risk if patient has already have a history smoking, alcohol, impulse behaviour
Reduce dose of dopamine receptor agonist gradually and monitor withdrawal symptoms
Offer CBT if dose reduction not effective
161
Fibrotic reactions and PD
Monitor for dyspnoea, persistent cough, chest pain, cardiac failure and abdomen pain
Higher dopamine receptor agonists; ergot derived
162
Stopping PD drugs
Never stop abruptly
Increases risk of neuroleptic malignant syndrome (high fever, confusion, ridged muscles, sweating, fast HR)
163
Nausea and vomiting in Parkinson disease
Domperidone as it doesn’t cross BBB
164
Antiemetics
Only prescribe when cause of vomiting is known
Can be unnecessary and harmful
Choose drug in accordance to aetiology
Antihistamines are effective and phenothiazines
165
Phenothiazines
Prochloperazine, perphenazine
Dopamine antagonists and block chemo trigger zones
Good prophylaxis and treatment in radiation sickness caused by opioids, cytotoxics and general anaesthesia
Severe dystonic reactions especially in children
Prochloperazine less sedating than chlorpromazine
166
Domperidone
Dopamine receptor antagonist
CI; severe hepatic impairment, impaired cardiac conduction
MHRA;, Max 7 days supply and 12+, 10 mg TDS
Severe interaction QT prolongation drugs
Acts on chemoreceptor trigger zone
Good for PD patients as it doesn’t cross BBB
Report signs arrhythmias MHRA risk cardiac s.e
167
Metoclopramide
MHRA neurological adverse effects
Max 5 day use risk of neurological adverse effect
S/e cause acute dystonic reactions; interact PD drugs, 18+
Acts on GIT vomiting associated with hepatic, gastroduodenal disease
CI; GI related complications
Avoid long term treatment due to developing EPS and tardive dyskinesa
168
Postoperative nausea and vomiting
Granisetron and ondasteron; nausea and vomiting following cytotoxic and post-op nausea
S/e cause QT prolongation
Dexamethasone; vomiting in cancer chemotherapy
Also use promethazine, phenothiazine (e.g prochloperazine) antihistamine
Combination of different classes maybe needed in high risk
169
Motion sickness
Prevent motion sickness rather than after N&V develops; as its given before journeys
Hyoscine hydrobromide; Kwells kids >4 years or Kwells >10 years, scopoderm patches
Promethazine; avomine 5+, phenagan
170
Prochloperazine
Is a P; Buccastem M; nausea and vomiting associated with migraine >18 years old
1-2 tablets BD for max 2 days
POM for nausea
171
Terminally ill patients and nausea and vomiting
Haloperidol and levomepromazine
172
Vomiting in pregnancy
In 1st trimester usually mild and doesn’t require drug therapy; rest, Oral rehydration, dietary changes, ginger
Promethazine, prochloperazine, metoclopramide; rare occasions when N/V is severe
Short term antihistamines if severe if symptoms dont settle 24-48 hours seek specialist
Risk hyoeremesis gravidarum; serious as it requires antiemetic therapy and fluids
173
Vestibular disorder (balance disturbance)
Meunière disease - ENT to confirm diagnosis
Betahistine; licensed for vertigo, tinnitus and hearing loss associated with meniers disease (inner ear disorder)
Diuretics alone or combined with salt restricted diet may provide benefit in vertigo associated with Ménière’s disease
Antihistamines e.g cinnarizine and phenothiazines (prochloperazine) are also used to elevate nausea and vomiting in vertigo
Prochloperazine should be reserved for acute symptoms where possible
174
Sickle cell disease and pain
Paracetamol and NSAIDs
Codeine and dihydrocoedine
Severe crisis to give morphine or diamorphine
Avoid pethidine as it can cause seizures
175
Dental and orofacial pain
NSAIDs and paracetamol used temporarily
Benzydamine mouthwash or spray used
Combining with non-opioid with an opioid can provide more relief than either on its own
Diazepam; has muscle relaxant and anxiolytic properties; prescribed only for short term
176
Dysmenorrhea
Period pain
Antiemetics can be used to prevent vomiting
Paracetamol or NSAIDS used to provide relief
Oral contraceptives can be used to prevent pain associated with ovulation cycles
177
Non-opioid analgesics
Aspirin indicated for headaches, musculoskeletal pain, dysmenorrhea and pyrexia
GI problems; take with or after food, use MR or e/c but has a slower onset of action
Paracetamol is safe and preferred; overdose = hepatic damage
Nefopam POM; used if pain is not responding to non-opioid analgesics but has more s/e; choose this over opioids as it wouldn’t cause respiratory depression
178
NSAIDS
Pain and inflammation
Mild-moderate MSK pain, post op pain, pain secondary to bone tumours, dysmenorrhea
Short term use
Selective COX2 preferred with pts with high risk S/E
179
Compound analgesic preparations
Compound preparation e.g co-codamol commonly used but can’t titrate
Caffeine is a weak stimulant and enhances analgesic effect
Co-proxamol tablets no longer licensed because of safety concerns
180
Opioid analgesics and dependence
Used to relief moderate to severe pain
Repeated use may cause dependence and tolerance
Caution in impaired respiratory function (avoid in COPD), asthma, hypotension, shock, convulsive disorder
181
Side effects of opioids
Respiratory depression ; treated by artificial ventilation or naloxone
Dependence and withdrawal; long term use develop tolerance
Overdose; coma, respiratory depression and pinpoint pupils
N/V, dry mouth, drowsiness, long term use (adrenal insufficiency, hypogonadism)
182
Pain ladder
Non-opioids
Weak opioids
Strong opiods
183
Pregnancy and opioids
Respiratory depression and withdrawal symptoms reported gastric stasis and inhalation pneumonia
184
Morphine
Gold standard
Most valuable opioid analgesic for severe pain
185
Buprenorphine
Espranor
Opioid agonist and antagonist properties
May precipitate withdrawal symptoms
Abuse potential and may cause dependence
Longer duration of action than morphine
Effective sublingually for 6-8 hours
Effects are only partially reversed by naloxone
Patches; avoid head as it can increase absorption, dry non irritated area
186
Oxycodone
Similar to morphine
Main use is pain control in palliative care
187
Neuropathic pain
Damage to neuronal tissue
Amitriptyline, nortiptyline, pregabalin, gabapentin and tramadol
Lidocaine plasters
Capsaicin cream
188
What is values for breaththrough pain dose
1/6th to 1/10th of the regular dose
189
Dose increase of regular opioid dose?
Not to be increased more than 1/3rd to 1/2 of it
190
Opioid-induced constipation with no help from conventional laxatives
Use methylnaltrexone
191
Treatment of acute migraine
Aspirin, paracetamol
Triptan if above ineffective
Antiemetics such as buccaste M if needed
Excess use of medication can lead to overuse headache
OTC sumatriptan 18-65 year old
192
Cluster headaches
Treat sumatriptan or zolmitriptan
Triggers; alcohol, smoking and volatile substances
Severe recurrent pain around the eyes last 15-30 mins
193
Migraine prophylaxis
Only considered
Suffer 2/+ attacks per month
Increasing frequency and headaches
Sig disability despite suitable treatment or cant use treatment for migraine
Medications used; BB, TCAs, gabapentin etc
194
Red flags for headaches
Sudden severe onset and new >50 Years
Progressive or persistent headache
Fever, neck pain/stiffness or photophobia
Recurrent head trauma with similar symptoms
Current or recent pregnancy (pre-eclampsia)
<12 years old with no signs of systemic infection
Numbness/weakness of arms (stroke)
195
Tension headache
Tight or pressing sensations around the head
Stress, anxiety, poor posture, tiredness, dehydration
Self-limiting but can use simple analgesia
196
Hypnotics and anxiolytics
Hypnotics sedate in the day
Anxiolytics sedatives will help induce sleep at night
Dependence and tolerance can occur
Short term use
Withdraw gradually esp if long term used
197
Protocol for withdrawal of long term benzodiazepines
Transfer patients to equivalent dose of diazepam (preferably at night)
Reduce diazepam dose by 1-2 mg evert 2-4 weeks
Reduce further in accordance to withdrawal symptoms
198
Hypnotics for insomnia
Establish cause and use in insomnia
Short acting preferred in elderly or those not wanting sedation the following day
Long acting; for patients who have poor sleep maintenance e.g waking in early morning and sleep day
Short term insomnia related to emotional problems or medical illness
Chronic insomnia for psychiatric disorders
Withdrawal can cause rebound insomnia
199
Elderly and hypnotics
Avoid benzodiazepines and Z-drugs as there is a greater risk of becoming ataxia and confused = falls and injjurt
200
Hypnotics and dental patients
Anxious patients may benefit
Temazepam or diazepam
Short acting temazepam preferred when it is important to minimise any residual effects the following day
201
Z-drugs
Zopiclone zolpidem and zaleplon
Non-benzo hypnotics
Act on benzodiazepine receptors
Not licensed for long term use
Zolpidem and zopiclone have short duration of action
Sleep onset insomnia, elderly patients little hangover effect
Short term use up to 4 weeks for severe insomnia that interferes with daily life
202
Melatonin
Pineal hormone
Licensed for short term treatment of insomnia
For adults 55+ or LD
203
Buspirone
Acts on HT1A receptors
Response can take up to 2 weeks
Doesn’t alleviate symptoms of benzodiazepine withdrawal
204
Barbiturates and insomnia
Only used in severe cases
Phenobarbital only value in epilepsy
Thipental is short acting used in anaesthesia
Increased hostility and agression indicated intoxication
205
Nicotine dependence drugs used
Nicotine replacement therapy
Bupropion (Zyban)
Smoking cessation
206
Nicotine replacement therapy
Patches slow release 16 h or 24 h
Longer release for patients how have stronger craving when waking up
IR are lozenges, gum etc
S/e; depends on the formulation; oral spray causes parasthesia, patches cause abnormal dreams (remove before bed), lozenges and oral spray (hot flushes and rash), Patches and oral spray sweating and myalgia
207
Opioid dependence
Medical, social and psychological treatment; multidisciplinary action
Methadone and buprenorphine used as substitution therapy
Review regularly and monitor for signs of toxicity
208
Methadone missed collections
Report patients that miss 3/+ doses as their at risk of overdose
Consider reduction in the dose by 50% for these patients
5 days needs assessing for illicit drug use before starting therapy again
Reporting to key workers
209
Methadone
Long acting opioid agonist - OD
More pronounced sedative effect
210
Buprenorphine as opioid therapy
Less sedating than methadone
So suitable for employed or those operating skilled tasks
Safer than methadone when used with other sedating drugs and less interactions
Milder withdrawal symptoms and dose reduction is easier than with methadone
Lower risk of overdose than methadone
211
Opioid substitution during pregnancy
Acute withdrawal of opioids should be AVOIDED in pregnancy
Risk higher than the benefit of withdrawal as it can lead to foetal death
1st trimester withdrawal can lead to spontaneous miscarriage
212
What drug is used to prevent relapse
Naltrexone
213
Opioid overdose antidote
Naloxone
214
Alcohol dependence
Alcohol withdrawal syndrome; seizures, deliriums, tremors or death
Long acting benzo (chlordiazepoxide or diazepam)
Lorazepam (quick acting) for alcohol induced seizures or delirium tremors medical emergency can use haloperidol or parental lorazepam as adjunction therapy
Acamprosate, Naltrexone used and
Disulfiram; can cause disulfiram alcohol reaction to any alcohol including perfume
215
Wernicke’s encephalopathy
High risk if alcohol dependent, malnutrition or decompensated liver disease
Treat parenteral thiamine followed by oral thiamine
216
Types of pain
Nociceptive pain; MSK (non-opioids esp NSAIDS), dental pain (NSAIDs, find route cause), moderate to severe visceral pain (opioids), period pain (oral contraceptives, antispasmodics or non opioids)
217
WHO pain ladder
Start non opioids (paracetamol and aspirin or NSAIDs) for mild pain
Weak opioids; codeine, dihydrocodeine, tramadol (add an non-opioid or adjuvant)
Strong opioids (morphine, oxycodone, etc) add an adjuvant or non opioids
Step up if the pain persists or increases
Consider prophylactic laxatives to avoid constipation with opioids
218
Adjuvants in pain ladder
Neuropathic pain; amitriptyline, nortriptylline, gabapentin and pregabalin
Bone metastases; biphosphonates, strontium ranelate
Nerve compression by tumour; dexamethasone
219
Paracetamol
Mild to moderate pain and fever
Preffered in the elderly
0.5 to 1 g every 4-6 hours as required MAX dose 4 g per day
Overdose - liver damage (esp under 50 kg), treat with acetyclysteine
Symptoms of overdose. N/V, right subcostal pain or tenderness
220
Aspirin
As an antiplatlet; 300 mg disp tablet as a medical emergency OR
Secondary prevention og thrombotic arterial event is 75 mg OD for life
As an NSAID use for pain and fever 300-900 mg every 4-6 hours when required MAX 4 g
CI - under 16 (Reyes syndrome), salicylate or NSAID hypersensitivity
Increased risk of bleeding
S/e; gastric irritation (take with food or just after), tinnitus in high doses
Avoid enteric coating in rapid relief or medical emergencies as it has a slower onset of action titme
221
Opioids
Weak opioids; codeine, dihydrocoedine and meptazinol
Moderate opioids; tramadol
Strong opioids; morphine, oxycodone, diamorphine, Buprenorphine, fentanyl, methadone
222
Breath-through pain dose
Rescue doses 1/10th or 1/6th of the total daily dose of strong opioids every 2-4 hours as required
Rescue preparation; IR
223
Naloxone
Revere sees respiratory depression
Can be supplied without a prescription to a friend / family member by drug treatment services for the purpose of saving a life in an emergency
224
Opioid side effects
Dry mouth
Nausea and vomiting - use antiemetic e.g metoclopramide
Constipation - senna and lactulose (faecal softener and stimulant)
Sedation - driving impaired
Reduced concentration and confusion
Euphoria, hallucinations
Dependence and tolerance
Respiratory depression
Euphoria
Long term; hypoganadism, adrenal insufficiency and hyperalgesia
225
Contra indications of opioids
Comatose patients - neurological depression and sedation
Risk of paralytic ileus - opioids reduce GI motility
Respiratory depression - as opioids reduce drive
Head injury or raised intracranial pressure
226
Opioid interactions
Increased sedation - with antidepressants, antihistamines, Z-drugs, antispychotics, antiepileptics and benzodiazepines
Possible CNS excitation or depression - MAOI
227
Morphine
Also used in coughs in palliative care
Severe pain in palliative care
Causes most nausea and vomiting, euphoria
Max dose increments; 1/3 or 1/2 of total daily dose per. 24 hours
Alternative is oxycodone which has similar efficacy and side effect profile
228
Diamorphine
Heroine
Preffered over morphine when administering parenteral
More soluble and smaller volumes can be injected in emancipated patients in palliative care
Equivalent to 1/3rd of an oral morphine dose
Less nausea and hypotension than morphine
229
Buprenorphine
Partial agonist - precipitates withdrawal symptom
Partially reversed by naloxone
Mainly a patch; 72 hours, 96 hours and 7 day patch os long acting
Available sublingually for opioids dependence
230
Fentanyl
72 hour patch
Long acting
Risk of fatal respiratory depression in opioid naive patients
Patient counselling; immediately remove patch in case of breathing difficulties
Switching to hyperalgesia reduce dose of new opioid by 1/4 to 1/2
Unsuitable in acute pain or rapidly changing - only use if pain level is stable
Avoid exposure to external heat - avoid hot baths or sauna and monitor if fever present
Apply; dry, non-irritated and non-hairy on upper torso or upper arm, rotate patch site after each use
231
Codeine MHRA alert
MHRA/CHM - restricted use in children due to reports of morphine toxicity, only given to above 12 if cannot be relieved by other painkillers.
12 to 18 years; max dose 240 mg for 3 days daily up to QDS with no less than 6 hour intervals
Not recommended in children with compromised breathing
Codeine for cough and cold - restricted use in children
232
Codeine
Used in mild to moderate pain
30 to 60 mg every 4 hours
Codeine linctus in drug or painful cough
Acute diarrhoea
Never give intravenously - severe reaction similar to anaphylaxis
233
Codeine contra indications
Ultra rapid metabolisers - CYP2D6 (morphine toxicity)
Children under 18 years who undergo removal of tonsils or adenoids for treatment of obstructive sleep apnoea
234
Codeine and breast feeding
Do not give to breast feeding mothers as it is passed to baby through breast milk
235
Codeine and patient counselling
Recognise signs and symptoms of morphine toxicity
Stop and seek medical attention - reduce consciousness, lack of appetite, somnolence, respiratory depression, constipation, pinpoint pupils, nausea and vomiting
236
Dihydrocoedine MHRA/CHM
Co-dydramol
Prescribe and dispense by strength to minimise risk of medication error and risk of accidental overdose
237
Tramadol
S/e; increased risk of bleeding, lowers seizure threshold, psychiatric reactions
Interactions - lowers seizure threshold (SSRIs, TCAs, Antiepileptics), increased serotonergic effect; risk of serotonin syndrome (SSRIs, TCAs, 5-HT1 agonists, MAOIs)
Increased risk of bleeding (bleeding )
238
Neuropathic pain
Tricyclic antidepressants - amitriptyline, nortriptyline
Antiepileptics - gabepentin, pregabalin
Opioid analges -if there is an inadequate response to other drugs
Compression - neuropathy; corticosteroids
Trigeminal neuralgia - carbamazepine or phenytoin
Localised pain ; topical local anaesthetic or capsaicin cream
239
Types of insomnia
Transient insomnia; causes environmental factors such as noise, shift work, jet lag. Use short acting (rapidly eliminated)
Short-term insomnia; emotional problems or serious medical illness, may last a few weeks and may recur. Take intermittently and omit some doses, give for no more than 3 weeks
Chronic insomnia; psychiatric disorders e.g anxiety and depression, alcohol and drug abuse, pain, dyspnoea and pruritis and treat underlying cause
240
Side effects of Z drugs
Paradoxical effects - increase in hostility and aggression. Talkativeness and excitement to aggression and antisocial acts. Can increase anxiety. Adjust dose to attenuate the impulse
Daytime sleepiness - avoid alcohol, CNS depression enhanced
Avoid long-term use - dependence and withdrawal reactions, tolerance develops in 3-14 days of continuous use
241
Narcolepsy
Rare long term brain disorder that causes a person to suddenly fall asleep at innaproprate times
Symtpoms; sleep attacks, excessive paralysis, cataplexy, sleep paralysis, excessive dreaming
