Central Nervous System Flashcards
(222 cards)
1
Q
What are the different types of dementia?
A
Alzheimer’s, vascular, Lewy body, mixed, frontotemporal
2
Q
What is the most common type of dementia?
A
Alzheimer’s
3
Q
How do we treat the cognitive symptoms of Alzheimer’s disease?
A
First line: Anticholinesterase inhibitor monotherapy: e.g. donepezil, rivastigmine or galantamine.
Second line memantine
4
Q
How do we treat cognitive symptoms of non-Alzheimer’s dementia?
A
Do monotherapy with acetylcholinesterase inhibitors like donepezil or rivastigmine (all unlicensed) but use galantamine only if the first two aren’t tolerated
5
Q
When do you treat the cognitive symptoms of vascular disease?
A
Only when they have co-morbidities such as Alzheimer’s disease, Parkinson’s or lewy body dementia
6
Q
What class of drug in Memantine?
A
NMDA receptor antagonist
7
Q
What is the MHRA warning with giving antipsychotics to dementia patients?
A
Increased risk of stroke and small increase of risk of death in patients who have dementia
8
Q
When do we give antipsychotics to patients with dementia?
A
ONLY if they are at risk of harming themselves or others/having crazy wild mental delusions (poor huns) (review every 6 weeks)
9
Q
What is rivastigmine also used to treat?
A
Parkinson’s disease
10
Q
Side effect of galantamine?
A
Serious skin reaction- stop medicine
11
Q
Side effects of rivastigmine?
A
Weight loss
12
Q
What is the first line for cognitive symptoms in moderate Alzheimer’s?
A
Memantine
13
Q
Side effect of memantine
A
Can cause convulsions
14
Q
Are acetylcholinesterase inhibitors or memantine recommended in patients with frontotemporal dementia or cognitive impairment associated with multiple sclerosis?
A
No
15
Q
How do you treat aggression in dementia patients?
A
Benzodiazepines, antipsychotics (only if worth it)
16
Q
List some CHOLINERGIC side effects
A
Diarrhoea, urination, muscle weakness, bronchospasm, bradycardia (opposite of anticholinergics), saltivation, sweating, emesis, lacrimation (teary eyes)
17
Q
Which antiepileptics can you take once daily as they have a longer half-life?
A
Perampanel, lamotrigine, phenytoin, phenobarbitone
18
Q
Which antiepileptics are in category 1 (advised to maintain on same product)?
A
Carbamazepine, phenytoin, phenobarbitone, primidone
19
Q
Which antiepileptics are in category 2 (based on clinical judgement and patient consultation)?
A
Valporate, amotrigine, clonazepam, topiramate
20
Q
Which antiepileptics are in category 3 (do not need to maintain on same product)?
A
levetiracetam, gabapentin, pregablin, ethosuximide
21
Q
Which is first line for tonic-clonic seizures?
A
Valproate or lamotrigine
22
Q
Which is first line for partial/focal seizures?
A
Lamotrigine or carbamazepine
23
Q
Which is first line for myoclonic seizures?
A
Valproate
24
Q
Which is first line for atonic/tonic seizures?
A
Valproate or lamotrigine
25
Which is first line for absence seizures?
Ethosuximide or valproate
26
What is antiepileptic hypersensitivity syndrome?
A potentially fatal syndrome which occurs within 1-8 weeks of exposure of antiepileptics, it causes a rash, haem, multi organ failure, liver, renal fever etc. Drug should be withdrawn immediately but avoid abrupt withdrawal- GRADUAL as can cause withdrawal seizure even if seizure free for years. Patient must not be re-exposed.
27
What is the MHRA warning with antiepileptic drugs?
There is a small risk of suicidal thoughts and depression, symptoms may occur up to one week after starting the treatment
28
How long must a patient wait to start driving again (VW Golf lol) if they have had an unprovoked seizure? (not epileptic)
6 months
29
How long must a patient be seizure free if they have epilepsy?
1 year (NB: patients can also do this if they have an established seizure pattern where it doesn’t affect their consciousness, they must also have no history of unprovoked seizures- 1 year but 3 years for established asleep attacks without awake attacks but also history of no awake seizures for 1 year)
30
Which vehicles can epileptics not drive?
Large goods or passenger carrying vehicle
31
List some drugs which lower the seizure threshold
Quinolones, carbapenems, SSRIs, TCAs, antipsychotics, tramadol, methadone
32
How long does the driving ban last when doses etc of anti-epileptics are changed?
6 months after last dose and DURING medication dose changes or withdrawal
33
Which anti-epileptics are present in high amounts in breast milk?
Ethosuximide, zonisamide, lamotrigine, primidone (ZELP)
34
Which anti-epileptics are associated with drowsiness with the infant?
Phenytoin and phenobarbitone and benzodiazepines
35
Which anti-epileptic gives the highest risk to the baby when Mum is pregnant?
Sodium valproate (30-40% developmental disorders)
36
Which other anti-epileptics are associated with increased teratogenicity?
Phenytoin, primidone, phenobarbital, lamotrigine, topiramate and carbamazepine
37
Which anti-epileptic has increased risk of congenital malformations i.e., cleft palate?
Topiramate
38
What do we give to reduce the risk of neural tube defects?
Folic acid 5mg OD during conception and throughout first trimester
39
Which anti-epileptics are considered to be the safest in pregnancy?
Levetiracetam and lamotrigine
40
Which doses should be changed during pregnancy if a patient is already on this anti-epileptic?
Lamotrigine, phenytoin, carbamazepine – base on drug-plasma concentration
41
Which drugs do we measure foetal growth with?
Levetiracetam and topiramate
42
What is the MOA of phenytoin?
It binds to neuronal sodium channels in their inactive state, prolonging inactivity
43
What type of seizures does phenytoin exacerbate?
Myoclonic and absence seizures
44
What is the therapeutic range for phenytoin?
10-20mg/L
45
Is there a linear or non-linear relationship between phenytoin and its concentration?
Non- linear (small changes in dose/missed doses/absorption can = large changes in concentration because phenytoin is a highly protein bound drug. When protein binding is reduced, monitor the free plasma concentration, this changes in pregnancy, children, elderly and liver failure. These three groups easily show signs of toxicity.
46
What is the patient safety alert with phenytoin?
The use of injectable phenytoin is error-prone through prescribing, preparation, administration and monitoring processes. All relevant staff should be made aware there is a HIGH risk of death and severe harm from error.
47
What are the signs and symptoms of toxicity for phenytoin?
SNAtCHeD:
Slurred speech
Nystagmus
Ataxia (lack of voluntary moving and co-ordination of muscle movement), confusion,
Hyperglycaemia,
Diplopia (double vision) and Blurred vision
48
What are the side effects of phenytoin?
Gingival hyperplasia, thickening/coarsening of facial features, acne, blood dyscrasias (watch out for signs of infection), hypersensitivity (antiepileptic hypersensitivity syndrome), rashes, low vit D (as induced vit D metabolism), hepatotoxicity, suicidal ideation
49
MOA of carbamazepine
Inhibits neuronal sodium channels and stabilises membrane potential and reduces neuronal excitability.
50
What types of seizures do carbamazepine exacerbate?
Atonic, clonic and myoclonic
51
What is the therapeutic range of carbamazepine?
4-12mg/L
52
When do you monitor the therapeutic range of carbamazepine?
1 to 2 weeks after
53
What are the signs of carbamazepine toxicity?
I-HANDBAG:
in-coordination, Hyponatraemia,
Ataxia,
Nystagmus,
Drowsiness,
Blurred vision and diplopia,
Arrhythmias,
Gastrointestinal disturbance (N+V+D)
54
What are the side effects of carbamazepine?
Blood dyscrasias (monitor signs of infection), hepatotoxicity, antiepileptic hypersensitivity syndrome, rash, hyponatraemia
55
List some interactions with carbamazepine?
Enzyme inducers (CRAPGPS), enzyme inhibitors (SICKFACES.COM), further
hyponatraemia (PPIs, diuretics, SSRIs, TCAs, NSAIDs),
decreased seizure threshold
(quinolones, SSRIs, TCAs, macrolides, tramadol, methadone, mefloquine),
increased risk of hepatotoxicity (isoniazid, fluconazole, alcohol, statins, tetracyclines, methotrexate),
as carbamazepine is a CYP450 inducer itself, it reduces the conc of warfarin, contraceptives etc
56
What kind of contraception are you allowed with PPP?
If using user independent methods, 1 of: IUD, POP implant, sterilization. If user dependent: COC+ barrier + regular pregnancy test
57
What are the patient materials for risk minimisation support materials?
Patient alert card, patient leaflet, patient guide, annual risk acknowledgement form
58
Every time a pharmacist dispenses sodium valproate to a female, what must they do/provide?
Valproate patient card, reminder of risks in pregnancy and need for highly effective contraception, ensure annual review and need for it, dispense whole original pack, all packs must have warning label on or sticker, the PIL, ensure they have read the patient guide, if a patient is NOT taking highly effective contraception – refer to GP
59
What are the side effects of sodium valproate?
Hepatotoxicity, pancreatitis, blood dyscrasias
60
What is status epilepticus?
Continuous seizures lasting longer than 5 minutes
61
What is the treatment for status epilepticus?
Oxygen if needed, thiamine if alcohol induced, position to avoid injury, maintain BP and correction of any hypoglycaemia… IV LORAZEPAM (repeat once after 10 mins if fails). Although diazepam can administered via rectal solution or midazolam oromucosal solution- buccal cavity.
If seizures fail to stop after 25 minutes, phenytoin/fosphenytoin should be used and contact ITU if seizures continue>
If after 45 mins, anaesthesia with thiopental or midazolam or propofol with full ITU support.
62
Why do we use IV lorazepam over diazepam?
Diazepam has a risk of thrombophlebitis IV, PR (suppositories) or IM is too slowly absorbed for efficacy.
63
How do you treat febrile convulsions?
Paracetamol, if >5 treat as status epilepticus
64
Who do we avoid lamotrigine in?
Parkinson’s disease and myoclonic seizure patients
65
What class of CD is gabapentin?
Schedule 3
66
What is the MHRA alert with gabapentin?
Risk of respiratory depression
67
Side effects of topiramate
acute myopia (short sightedness) with secondary angle glaucoma
68
What class of CD’s are benzodiazepine’s?
CD4 part I
69
Which Benzodiazepine is longer acting and which is shorter acting out of lorazepam and diazepam?
Diazepam is longer acting, and lorazepam is shorter acting
70
What is the elderly STOPP criteria? (prescription potentially inappropriate)
A duration of 4 weeks or longer, if with acute or chronic respiratory failure, patients prone to falls
71
What is ADHD?
Attention deficit hyperactivity disorder, characterised by: hyperactivity, impulsivity, inattention
72
First line treatment for ADHD?
Lisdexamfetamine or methylphenidate, if one not work switch to another in 6 weeks (NB: dexamfetamine can be trialled if patients having beneficial effect to lisdexamfetamine but cannot tolerate longer duration of effect – unlicensed)
second line: atomoxetine
73
What are the side effects of atomoxetine?
Sexual dysfunction, changes in sleeping patterns
74
What class of drug is methylphenidate?
Class 2
75
What are the side effects of methylphenidate?
Growth restriction in children, appetite loss, insomnia, tachycardia and hypertension, tics and tourette’s syndrome
76
What do you monitor with methylphenidate?
Blood pressure and pulse (as causes HTN and tachycardia), height and weight (as causes growth restriction), psychiatric symptoms eg depression, psychosis and suidal ideation
77
How do you prescribe methylphenidate? (formulation wise)
By modified release brand preparations
78
Regarding antipsychotics, how often can you change the dose?
Maximum once weekly
79
Generally, with antipsychotics, do they help positive or negative symptoms?
Positive symptoms i.e. hallucinations, thought disorder, delusions
80
How do first generation antipsychotics work?
By blocking the dopamine D2 receptors in the brain
81
What does EPSE stand for? What are they?
Extrapyramidal side effects: PDAT =parkinsonism (tremor), dystonia (weird body/face movements), akathisia (restlessness), tardive dyskinesia (rhythmic involuntary movements of face, tongue and jaw
82
What other side effects do antipsychotics have?
Hyperprolactinaemia, sexual dysfunction, CV effects, hyperglycaemia and weight gain, hypotension and interference with temp regulation, neuroleptic malignant syndrome, blood dyscrasias
83
Give some examples of second-generation antipsychotics
Clozapine, olanzapine, quetiapine, risperidone, aripirazole
84
Are first gen or second generation more likely to cause EPSE?
First generation
85
Which generation antipsychotics are more likely to cause metabolic side effects?
Second generation
86
Which generation of antipsychotics have a better effect on negative symptoms?
Second generation
87
What do you do to the dosage of antipsychotics with elderly patients with dementia?
Halve the dosage due to risk of stroke and death
88
Why do antipsychotics cause hyperprolactinaemia?
Because they reduce dopamine levels and dopamine inhibits prolactin
89
Which is the only antipsychotic that reduces prolactin levels and why?
Aripiprazole because it is a partial dopamine agonist also, so more levels of dopamine = higher inhibition of prolactin = lower levels
90
What are the MHRA alerts with clozapine?
Monitor blood concentrations for toxicity, potentially fatal risk in intestinal obstruction or faecal impaction and paralytic ileus. NB: myocarditis cautioned in clozapine
91
What monitoring is required with clozapine?
Leucocytes every week for 18 weeks, then fortnightly for up to a year, then monthly.
Blood lipids and weight at baseline, 3 months, then 12 months
Fasting BMs at baseline, 4-6 monthly, then 12 months then yearly
Hepatic function regularly
BP during initiation
92
When is clozapine initiated?
When unresponsive to 2 antipsychotics have not worked for 6-8 weeks
93
What is the monitoring for all antipsychotics?
FBC, U+Es, LFTs, glucose initiation and annually,
weight and lipids baseline, 3 months, then yearly,
ECG before initiation, BP before starting and with any dose changes,
prolactin initiation, 6 months then yearly
94
If a patient has been on long term antipsychotics (especially clozapine), there is a high risk of relapse if stopped. How do you reduce this?
Gradual withdrawal, monitor for 2 years after withdrawal
95
What are the symptoms of neuroleptic malignant syndrome?
High fever, confusion, variable BP, HR, ridged muscles
96
How do you treat acute episodes of bipolar?
A) Initial stages – BZs but don’t use for long periods
B) antipsychotic drugs (olanzapine, quetiapine or risperidone)
C) Lithium or valproate if inadequate response (+/- antipsychotic)
Long term therapy generally: Olanzapine (+/- lithium or valproate) if patient has frequent relapse/continuing functional impairment.
Carbamazepine can be used but ONLY in specialist situations where there is RAPID cycling manic depressions (4 or more affective episodes a year)
97
What do you do if someone is to have antipsychotics discontinued?
Withdraw over 4 weeks, dose reduce gradually IF THE PATIENT IS CONTINUING WITH OTHER ANTIMANIC DRUGS. If patient is not continuing with other antimanic drugs or if history of manic relapse have a withdrawal period of up to 3 months
98
How long can it take for lithium to work/have an effect?
6 months to 12 months
99
What is the narrow therapeutic range for lithium?
0.4-1mmol/L normally and 0.8-1mmol/L in mania patients
100
What is a lifestyle point that needs to be told to the patient when initiating lithium?
Maintain adequate hydration and salt intake (as toxicity is worsened by sodium depletion)
101
Lithium toxicity signs?
Seizures, coma, renal failure, arrythmias, BP changes, circulatory failure, death, polyuria, polydipsia, muscle weakness, confusion
102
What do you monitor with lithium toxicity and when?
Serum lithium concentration weekly until stable, then every 3/12, renal, thyroid and cardiac every 6 months
103
What colour is the lithium book?
Purple
104
What is the interaction between amiodarone and lithium?
Risk of ventricular arrhythmias increase with amiodarone and lithium
105
What is the interaction between methyldopa with lithium?
Increased risk of neurotoxicity (same with diltiazem and verapamil and carbamazepine)
106
List some MAOIs
moclobemide, tranylcypromine, isocarboxazid
107
List some TCAs
Amitriptyline, clomipramine, dosulepin (dangerous in overdose), imipramine (more antimuscarinic) etc
108
What class of drug is duloxetine?
SNRI
109
Which is the only SSRI that is given to children?
Fluoxetine
110
Which SSRI is safe to use in MI/unstable angina?
Sertraline
111
In depression, if you do not respond to an SSRI, what is second line?
A) switch to another SSRI or
B) increase dose
C) use mirtazapine Third line= add TCA
112
How long do you have to leave before starting new antidepressive treatment after discontinuing MAOIs?
2 weeks
113
How long do you have to leave before starting new antidepressive treatment after discontinuing TCAs?
7-14 days (3 weeks for imipramine or clomipramine)
114
How long do you have to leave before starting new antidepressive treatment after discontinuing SSRIs?
A week , but 5 weeks for fluoxetine, 2 weeks sertraline
115
How often should a patient be reviewed when starting antidepressants?
Every 1-2 weeks at the start of Tx, continue for at least four weeks BUT six weeks in elderly, in partial response continue for another 1-2 weeks. Following remission, patients should have the same dose Tx for 6 months but 12 months in elderly
116
Which class of antidepressants is hyponatraemia more prominent in?
SSRIs
117
What are the characteristics of serotonin syndrome?
Twitching, clonus, rigidity, tachycardia, BP changes, hyperthermia, shivering, diarrhoea, altered mental state
118
Is sertraline licensed for anxiety or not?
No but it is still used
119
Which SSRI is associated with higher withdrawal effects?
Paroxetine due to shorter half life
120
What other indications is duloxetine used for?
Urinary incontinence and diabetic neuropathy
121
Why do we like to use mirtazapine for depression in the elderly?
Fewer antimuscarinic side effects, causes weight gain
122
What is the main cause of Parkinson’s disease?
Death of dopaminergic cells of the substantia nigra in the brain (reduction of dopamine)
123
What is the classic presentation for PD?
Rigidity, tremor, bradykinesia, postural instability
124
What are the two combinations with levodopa?
Co-careldopa (levodopa with carbidopa), co-beneldopa (levodopa with benserazide)
125
Give some examples of dopamine receptor agonists?
Ergot derived: bromocriptine, cabergoline, pergolide NOT RECOMMENDED.
Non- ergot derived: Pramipexole, ropinirole, rotigotine
Amantadine and apomorphine
126
Give examples of MAO-B Inhibitors
Selegiline and rasagiline
127
Give some examples of COMT inhibitors?
Entacapone, tolcapone
128
What is first line for PD?
(motor symptoms)- levodopa combination only when it affects QOL,
when motor symptoms not affecting QOL: either
a) levodopa combo
b) MAOB inhib
c) non ergot derived dopamine agonists
129
What if this first line of PD does not work completely?
Add on therapy with either MAOB inhibitor, dopamine receptor agonist (non-ergot derived), or COMT inhibitors
130
Which antiemetic do you use in PD?
Domperidone
131
When is the only time ergot derived dopamine receptor agonists are used?
When non ergot derived has not adequately controlled symptoms
132
What is amantadine useful for?
Dyskinesias- when they’re not adequately managed by current therapy
133
What is used for PD patients with sleep onset symptoms?
Modafinil – only used for sudden onset of sleep or daytime sleepiness
134
What is used for PD patients for postural hypotension?
If pharmacotherapy required- midodrine first line, fludrocortisone second line [unlicensed]
135
What is used for PD patients with psychotic symptoms?
Quetiapine. If not tolerated – clozapine. NB: phenothiazines and butyrophenones can worsen motor features of PD
136
What is used for PD patients drooling of saliva?
If SALT ineffective, Glycopyrronium bromide first line, botox second line
137
What is used for PD patients’ dementia?
Acetylcholinesterase inhibitor then memantine hydrochloride
138
What are the side effects of levodopa?
Impulse control disorders, excessive sleepiness/onset of sleep, motor complications i.e. dyskinesia’s or response fluctuations, end of dose deterioration with shorter length of benefit
139
What weight is domperidone unlicensed in?
Under 35kg
140
There are serious cardiac risk factors when using apomorphine and domperidone together (arrhythmia risk due to QT prolongation), what have the MHRA and CHM recommended to reduce this?
An assessment of cardiac risk factors and ECG monitoring to ensure benefits outweigh the risks
141
Levodopa-carbidopa intestinal gel is administered where?
Directly into the duodenum or upper jejunum (with a portable pump)
142
When is apomorphine SC intermittent injections or continuous infusion offered?
When a patient has refractory motor fluctuation ‘off’ episodes
143
What are the side effects of dopamine receptor agonists?
Impulsive control disorders, excessive sleepiness and sudden onset of sleep, psychotic symptoms (i.e., hallucination and delusions), hypotensive reaction in first few days
144
What class of drug is amantadine?
A weak dopamine receptor agonist
145
Why can selegiline be considered as a driving offence?
Because it is metabolised to amfetamine
146
Why can you not have pseudoephedrine and rasagiline together?
They cause hypertensive crisis (same as with any sympathomimetic or any hypertensive drug)
147
What colour does entacapone colour the urine?
Reddish brown
148
What is the patient and carer advice for tolcapone?
Recognise signs of liver toxicity- anorexia, nausea, vomiting, abdominal pain, dark urine, pruritis, light stools
149
What is given to PD patients with rapid eye fluctuations?
Clonazepam or melatonin
150
Why can we not withdraw dopamine receptor agonists straight away?
Neuroleptic malignant syndrome
151
What class of drug is ondansetron?
5-HT3 receptor antagonist
152
What class of patients is ondansetron used in a lot?
Chemotherapy or post-operative patients for nausea and vomiting
153
What class of drug is domperidone?
Dopamine antagonist
154
What class of drug is metoclopramide?
Dopamine antagonist
155
Where does metoclopramide mainly work?
The GI tract- used for emesis in GI, hepatic and biliary disease
156
When are phenothiazines used in emesis?
diffuse neoplastic disease, radiation and sickness, emesis from opioids, general anaesthetic and cytotoxics
157
When is dexamethasone used as an antiemetic?
In cancer chemotherapy
158
What class of drug is Aprepitant?
Neurokinin-1 receptor antagonist
159
When is Aprepitant and fosaprepitant used/licensed?
N+V associated with emetogenic chemotherapy, and fosaprepitant for HIGHLY emetogenic cisplatin chemo
160
What class of drug is nabilone?
Synthetic cannabinoid
161
What is the first line antiemetic in pregnancy?
Drowsy antihistamines like promethazine. Prochlorperazine or metoclopramide are alternatives
162
Thiamine supplementation is given to patients with hyperemesis gravidarum to prevent what?
Wernicke’s encephalopathy
163
Age for cyclizine?
>6
164
Age for promethazine? (Phenergan)
>2 (OTC in cough/cold)
165
Age for cinnarizine?
>5
166
Age for prochlorperazine?
>18 buccastem- max 2 days.
167
What are the side effects of dopamine antagonist? (typical antipsychotics) in antiemetics
Dystonic reactions, postural hypotension, drowsiness, QT prolongation
168
What is the MHRA alert for domperidone?
Cardiac side effects- maximum treatment is for 7 days 10mg TDS, over 12y/o and >35kg
169
What is the MHRA alert for metoclopramide?
EPSE >18- for max only 5 days. Max 500mcg/kg daily (ondan also 5 days)
170
What antiemetic is also a prokinetic?
Metoclopramide and domperidone
171
What is used for motion sickness?
A) hyoscine hydrobromide
B) sedating antihistamines
C) antiemetic
172
Side effects with metoclopramide?
Acute dystonic reactions (especially facial and skeletal muscle spasms)
173
How do you abort the side effect of metoclopramide?
Procyclidine (it is an anti-parkinsonism drug)
174
If a drowsy antihistamine is desired for motion sickness, which would be used?
Promethazine, but generally non-sedating ones like cyclizine or cinnarizine is preferred
175
What is the dosing for cinnarizine for motion sickness OTC? (stugeron)
Take 2 hours before, they last 8 hours
176
What is the dosing for promethazine for motion sickness OTC? (Phenergan)
Give the night before or 1 hour before and it lasts 24 hours
177
What is the dosing for hyoscine hydrobromide for motion sickness OTC? (joy rides, travel calm, kwells)
(150mg <3 and 300mg <10) given 30 mins before and lasts 6 hours
178
What would we use for musculoskeletal pain?
Non-opioids, especially NSAIDs
179
What would you use for moderate to severe visceral pain?
Opioids
180
What do you use for neuropathic pain?
TCA’s (amitriptyline/nortriptyline), antiepileptics (gabapentin/pregabalin)
181
What are the two cautionary and advisory labels on paracetamol?
A) contains paracetamol, do not take anything containing paracetamol whilst ……
B) do not take any more than 2 at any one time, do not take more than 8 in 24 hours
182
What are the analgesia doses for aspirin?
300-900mg every 4-6 hours as required, maximum 4g a day
183
What are the two cautionary and advisory labels on aspirin?
Take with or just after food, or a meal AND contains aspirin, do not take anything else containing aspirin whilst taking this medicine
184
Why is aspirin contraindicated in under 16s?
Reye’s syndrome (exceptions in Kawasaki disease or as an antiplatelet)
185
What class of CD is dihydrocodeine?
Class 5
186
What class of CD is tramadol?
Class 3
187
What class of CD is morphine solution 10mg/5ml?
Class 5 (anything stronger than 13mg/5ml is CD 2
188
What class of CD is oxycodone?
Class 2
189
What class of CD is fentanyl?
Class 2
190
What class of CD is buprenorphine?
Class 3
191
What class of CD is tapentadol?
Class 2
192
What fraction of opioid do you give for breakthrough pain?
1/10th to 1/6th of total daily dose of strong opioid every 2-4 hours as required
193
What is the antidote for opoids?
Naloxone
194
How do you implement dose increases/increments in morphine patients?
Max dose increment = 1/3 or ½ of total daily dose per 24 hours. NB: equivalent parenteral dose (SC, IV, IM) = half of oral dose
195
What is the MHRA alert with codeine for children?
Codeine for analgesia: restricted use in children due to reports of morphine toxicity. For acute moderate pain in children OVER 12 only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen alone. Children aged 12-18= max 240mg daily for 3 days. Dosage = up to four times a day with no less than 6h intervals.
196
What is the MHRA alert with co-dydramol?
Prescribe and dispense by strength to minimise risk of medication error and risk of accidental overdose
197
What is the treatment for bone metastases?
Bisphosphonates, radiotherapy, pain management and strontium chloride isotropes
198
What is the treatment for trigeminal neuralgia?
Carbamazepine
199
What class of drug is a triptan?
5HT1 receptor agonist
200
What is the first line for migraines?
Monotherapy with either paracetamol, aspirin, ibuprofen or a 5HT1 receptor agonist if severe (generally 5-HT1 agonist second line)
201
How long do you have to wait to take a second dose of a triptan?
2 hours
202
What is first line for migraine prophylaxis?
Propranolol
203
What is the criteria to get migraine prophylaxis?
Suffer at least two attacks a month, increasing freq of headaches, significant disability despite treatment and cannot take suitable treatment for attacks
204
What is contained in migraleve?
Codeine, buclizine and paracetamol
205
Licensing for migraleve?
>12
206
Licensing for Imigran
>18 must be 18-65, clear diagnosis of migraine, not used for prophylaxis, cannot give to cardiac disease etc.
207
In what child age would you refer insomnia?
Under 12
208
What are the ages for diphenhydramine?
16 and over
209
Age for promethazine?
2 and over
210
How do you take promethazine?
Take 20-30 mins before going to bed, do not use for more than 7-10 consecutive nights
211
What CD classification is diazepam?
Schedule 4 part 1
212
What CD classification is diazepam?
Schedule 3
213
What treatments do we use for narcolepsy?
Modafinil, methylphenidate, dexamphetamine etc
214
What is acamprosate used for?
Alcohol dependence
215
How many days do you change the dose of methadone for when a patient has gone without it?
3 or more days (may be less tolerance so dose is decreased) NB if 2 days missed inform rehab but give same dose
216
How long does it take methadone to reach steady state (Css)?
3-10 days
217
Which is more sedating out of buprenorphine or methadone?
Methadone
218
What is suboxone?
An orally active version of buprenorphine and naloxone (prescribed for patients at risk of dose diversion as not orally active but injected would cause a bad reaction)
219
What do you use for diarrhoea and stomach cramps in heroin withdrawal?
Mebeverine for stomach cramps and loperamide for diarrhoea
220
List some immediate release formulations for NRT?
Lozenge, gum, inhalator, sublingual tablet, oral spray, nasal spray
221
How does varenicline work?
Selective nicotine receptor partial agonist, it is a competitive inhibitor of receptors
222
What is the MHRA alert with varenicline?
Suicidal behaviour, stop and see GP
