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Victor BNF Notes > Central Nervous System Part 1 > Flashcards

Central Nervous System Part 1 Flashcards

1
Q

How is dementia caused?

A

when the brain is damaged by disease such as Alzheimer’s, strokes or Parkinson’s

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2
Q

What are the Cognitive symptoms of Dementia

A
  • Memory Loss
  • difficulties thinking/concentrating
  • difficulties finding the right word
  • Losing track of date
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3
Q

What are the Non-cognitive symptoms of dementia

A
  • psychiatric and behavioural problems
  • difficulty with daily activities
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4
Q

Management of cognitive symptoms
(mild-moderate Alzheimer’s symptoms)

A

Acetylcholinesterase Inhibitors
- Donepazil
- Galantamine
- Rivastigmine

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5
Q

Donepazil interactions in Dementia

A

Concomitant use with Antiphycotics increased risk of Neuroleptic Malignant Syndrome

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6
Q

What is Neuroleptic Malignant Syndrome

A

fever, altered mental status, muscle rigidity, and autonomic dysfunction.

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7
Q

Galantamine cautions

A

Stop at first sight of skin rash or skin reactions

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8
Q

Rivastigmine forms

A

Rivastigmine causes GI symptoms, withhold until solved

Transdermal Patches cause less GI Disturbances

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9
Q

Management of cognitive symptoms
(moderate to severe Alzheimer’s symptoms)

A

NMDA Glutamate Receptor Antagonists

Memantine

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10
Q

Cholinergic Effects Anagram

A

DUMB BELLS

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11
Q

Cholinergic Effects Anagram D

A

Diarrhoea

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12
Q

Cholinergic Effects Anagram U

A

Urination

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13
Q

Cholinergic Effects Anagram M

A

Muscle weekness, cramps and Miosis

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14
Q

Cholinergic Effects Anagram B

A

Bronchospasm

Bradycardia

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15
Q

Cholinergic Effects Anagram E

A

Emesis (vomiting)

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16
Q

Cholinergic Effects Anagram L

A

Lacrimation (teary eyes)

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17
Q

Cholinergic Effects Anagram S

A

Salivation and sweating

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18
Q

Management of Non-cognitive symptoms in Dementia

A

Antipsychotic Drugs
(Severe)

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19
Q

Antipsychotics in elderly Dementia patients cautions

A

increased risk of stroke and death

assess benefits taking into account patient history of stroke/heart attack, diabetes and smoking

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20
Q

Non-Cognitive symptom treatment in Dementia (extreme violent behaviour)

A

Oral Benzodiazepines

or…

Antipsychotics

If intramuscular needed, use: (haloperidol, olanzapine, lorazepam)

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21
Q

Non-Cognitive symptom treatment in Dementia treatment (Dementia with Lewy bodies)

A

Lewy bodies are clumps of protein forming inside brain cells
(also found in parkinson’s disease)

Treatment:
Acetylcholinesterase Inhibitors (rivastigmine)

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22
Q

What is Epilepsy

A

a sudden surge of electrical activity of neurons in the brain

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23
Q

What are the 2 types of Non-epileptic seizures

A

Organic: hypoglycaemia / fever

Psychogenic:
mental processes (distressing thoughts)

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24
Q

Drug dose of most anti-epileptic dugs

A

twice daily

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25
Q

Drugs used to treat seizures Part 1

A
  • Barbiturates (phenobarbital long half life ON)
  • Benzodiazepines (clobazam, clonazapam, lorazepam, Midazolam)
  • Carbamazepine
  • Gabapentin, Pregabalin
  • Lamotrigine (long half life ON)
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26
Q

Drugs used to treat seizures Part 2

A
  • Levetiracetam
  • Phenytoin (long half life ON)
  • Sodium Valproate
  • Topiramate
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27
Q

Drugs used to treat seizures Part 3

A
  • Lacosamide
  • Perampanel
  • Rufinamide
  • Tiagabine
  • Vigabatrin
  • Zonisamide
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28
Q

Types of Epileptic Seizures

A
  • Focal partial seizures with / without secondary generalisation
  • Tonic-clonic seizures
  • Absence Seizures
  • Myoclonic Seizures
  • Atonic / Tonic Seizures
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29
Q

Focal Partial Seizures treatment (with/without secondary generalisation)

A

1st Line:
Lamotrigine or Carbamazepine

Alternative:
Levetiracetam, Valproate or Oxcarbazepine

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30
Q

Tonic-Clonic Seizures treatments (generalised)

A

1st Line:
Valproate or Carbamazepine

Alternative:
Lamotrigine

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31
Q

Absence Seizures treatments (generalised)

A

1st Line:
Ethosuximide or Valproate

Alternative:
Lamotrigine

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32
Q

Myoclonic Seizures (generalised)

A

1st Line:
Valproate

Alternative:
Topiramate, Levetiracetam

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33
Q

Atonic/Tonic Seizures (generalised)

A

1st Line:
Valproate

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34
Q

Some Anti-epileptic Drugs caution

A

potential harm when switching between different brands for epilepsy CATEGORY 3

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35
Q

Epilepsy Drug Categories

A

Category 1:
advised to stay on same product

Category 2:
Based on clinical judgement and patient consultation

Category 3:
Do not need to stay on same product

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36
Q

Epilepsy Drugs Category 1 Examples

A
  • Carbamazepine
  • Phenytoin
  • Phenobarbital
  • Primidone
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37
Q

Epilepsy Drugs Category 2 Examples

A
  • Valproate
  • Lamotrigine
  • Clonazepam
  • Topiramate
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38
Q

Epilepsy Drugs Category 3 Examples

A
  • Levetiracetam
  • Gabapentin
  • Pregabalin
  • Ethosuximide
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39
Q

Anti-epileptic drug withdrawal cautions

A
  • Gradually withdraw under specialist supervision
  • If done abruptly, sever rebound seizures can occur
  • If on combination therapy, withdraw 1 drug at a time
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40
Q

Epilepsy and Driving:
Your license will be taken away if you have

A
  • epileptic seizures while awake and lost consciousness
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41
Q

Anti-epileptic Drugs and Pregnancy

A
  • increased risk of teratogenicity
  • reduces effectiveness of hormonal contraception (Carbamazepine)
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42
Q

Anti-epileptic drugs and pregnancy high risk drugs.

A

Highest Risk
- valproate
- valproic acid

Increased Risk
- Carbimazapine
- Phenytoin
- Phenobarbital
- Lamotrigine

Increased chance of Cleft Palate (lip not joined properly)
- Topiramate in first trimester

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43
Q

What do anti-epileptic drugs have a risk of causing during pregnancy

A

Minor and major congenital malformations and long term development disorders

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44
Q

Which anti-epileptic drugs need to be dose adjusted due to changing drug plasma concentrations during pregnancy

A

Phenytoin

Carbamazepine

Lamotrigine

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45
Q

Which anti-epileptic drugs do you need to monitor foetal growth with

A

Topiramate

Levetiracetam

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46
Q

Refer to specialist when planning a pregnancy whilst taking anti-epileptic drugs, what are the options

A
  • Withdraw then resume after 1st trimester pregnancy

or…

  • Use mono therapy only
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47
Q

What is neural tube defect

A

occurs when the neural tube does not close properly

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48
Q

Which drug and dose reduces the risk of neural tube defect when taking anti-epileptic medication and when to take it

A

Folic Acid 5mg OD

taken before contraception up until 12 weeks after pregnancy

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49
Q

What must you do if you are a woman planning on getting pregnant while on epilepsy medication

A

Notify the uk epilepsy and pregnancy register

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50
Q

What is neonatal haemorrhage

A

a bleeding problem that occurs in a baby during the first few days of life

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51
Q

What reduces the risk of neonatal haemorrhage

A

Vitamin K injection in newborn

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52
Q

Which anti-epileptic medication can cause withdrawal effects in newborns

A

Benzodiazepines and phenobarbital

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53
Q

What to monitor on a baby during anti-epileptic drugs and breastfeeding

A

Drowsiness, weight gain, feeding difficulty, adverse effect, developmental milestones

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54
Q

Which anti-epileptic medication is present in high concentrations in breast milk

A

Lamotrigine
Zosinamide
Ethosuximide
Primidone

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55
Q

What anti-epileptic drug accumulates due to baby slow metabolism

A

Phenobarbital

Lamotrigine

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56
Q

What anti-epileptic drug inhibits sucking reflex

A

Phenobarbital

Primidone

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57
Q

What anti-epileptic drug increases risk of drowsiness in infants

A

Benzodiazepines

Phenobarbital

Primidone

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58
Q

What anti-epileptic drug should you avoid abrupt withdrawal of breastfeeding with

A

Phenobarbital

Primidone

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59
Q

Anti-epileptic drug side effects:
Anti-epileptic Hypersensitivity Syndrome

A

Rash, Fever, Lymphadenopathy (lymph node swelling)

Carbamazepine, Phenytoin, Phenobarbital, Primodine and Lamotrigine

Increased risk in concomitant use:

Phenytoin and Carbamazepine

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60
Q

Anti-epileptic drug side effects:
Suicidal Behaviour

A

report any mood changes, distressing thoughts or feelings of suicide

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61
Q

Anti-epileptic drug side effects:
Skin Rashes

A

Lamotrigine

Steven-Johnson syndrome and Epidermal Necrosis

If Lamotrigine is high initial dose, rapid dose increase or taken with valproate

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62
Q

What is Toxic Epidermal Necrosis

A

extensive exfoliation of the epidermis and mucous membrane, which may result in sepsis and death

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63
Q

What is Steven-Johnson syndrome

A

blistering and peeling of the skin and surfaces of the eyes, mouth and throat

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64
Q

What is Blood Dycrasias

A

any condition that affects the blood, bone marrow, or lymph tissue.

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65
Q

Anti-epileptic drug side effects:
Blood Dycrasias

C Vet Plz Acronym

A

Ethosuximide, Valproate, Carbamazepine, Phenytoin, Lamotrigine, Topiramate,
Zonisamide

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66
Q

Anti-epileptic drug side effects:
Eye Problems

A

Vigabatrin:
visual field deflects

Topiramate:
Acute myopia with secondary angle closure glaucoma

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67
Q

Anti-epileptic drug side effects:
Encephalopathic Symptoms

A

Vigabatrin

Marked sedation, stupor and confusion

withdraw or reduce dose

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68
Q

Anti-epileptic drug side effects:
Severe Respiratory Depression

A

Gabapentin

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69
Q

Patients at higher risk of Severe Respiratory Depression while using Gabapentin include…

A
  • Compromised respiratory function
  • Respiratory/neurological disease
  • Elderly
  • Renal impairment
  • concomitant use with CNS depressants
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70
Q

Anti-epileptic enzyme inducers (Carbamazepine, Phenytoin, Phenobarbital) interaction with interaction with oral contraceptives and warfarin…

A

decreases drug plasma concentration

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71
Q

Phenytoin (high risk drug as narrow therapeutic index) mode of action

A

binds to neuronal sodium channels in their inactive state; prolonging inactivity

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72
Q

What is phenytoin used for…

A

focal seizures and generalised tonic-clonic seizures. Exacerbates absence and myoclonic seizures (avoid)

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73
Q

Phenytoin therapeutic ranges…

A

10-20mg/L
or
40-80mcg/L

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74
Q

Neonate Phenytoin therapeutic ranges…

(below 3 months)

A

6-15mg/L
or
25-60mcg/L

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75
Q

Phenytoin has non-linear relationship between doses and drug plasma concentration, which means

A

Small change in dose/drug absorption

Large change in plasma concentration

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76
Q

Phenytoin high protein binding monitoring

A

During states of lowered protein binding in the body, plasma conc of phenytoin is increased.

Because phenytoin is a highly protein-bound drug

therefore plasma conc will increase

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77
Q

States of low protein binding in people

A
  • pregnancy
  • children (neonates)
  • elderly
  • liver failure
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78
Q

Symptoms of Phenytoin toxicity

A
  • Slurred Speech
  • Nystagmus (uncontrolled repetitive eye movements)
  • Ataxia
  • Confusion
  • Hyperglycaemia
  • Diplopia (double vision)
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79
Q

Phenytoin brand cautions

A
  • Phenytoin is risk 1 category epileptic drug
    — Different oral formulations vary in bioavailability
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80
Q

Switching between phenytoin products

A

Phenytoin sodium is not the sane bioavailability as phenytoin base

100mg Phenytoin Sodium = 92mg Phenytoin base

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81
Q

Side effects of Phenytoin Part 1

A
  • changes in appearance
    (coarsening of facial features) (gingival swelling)
  • Blood Dyscrasias (blood infections)
    (report signs of infection)

if leucopenia is severe: immediately withdraw drug

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82
Q

Side effects of Phenytoin Part 2

A
  • Hypersensitive reactions
    (report fever, rash, swollen lymph nodes)
  • Rashes (report them)
    (discontinue if rashes reappear)

Han Chinese and Thia Patients with HLA*1502 allele
have increased risk of Steven-Johnson syndrome

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83
Q

Side effects of Phenytoin Part 3

A
  • Low vitamin D
    (phenytoin induces vitamin D metabolism) (use vitamin D supplement)
  • Hepatotoxicity
    (discontinue immediately)
    — dark urine, nausea, abdominal pain, itching and jaundice
  • Suicidal Ideation
    (small increase with all anti-epileptic)
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84
Q

Side effects of Phenytoin Part 4

A
  • Bradycardia, Hypotension (IV Phenytoin) (prescribing dose needs to be accurate as risk of severe harm)

(monitor ECG and BP)

  • IV Fosphenytoin
    (cardiovascular reactions)
    — Asystole, ventricular fibrillation, cardiac arrest, heart block
    (monitor cardio function)
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85
Q

Phenytoin Sodium and Fosphenytoin dose equals

A

Fosphenytoin 1.5mg

Phenytoin Sodium 1mg

give fesphenytoin only IV and IM

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86
Q

Drugs that interact with Phenytoin to increase plasma concentration

A

Amiodarone, Cimetidine, miconazole, fluconazole, chloramphenicol,
Diltiazem,
Valproate, trimethirprom

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87
Q

Drugs that interact with Phenytoin to reduce its drug concentration

A

Therapeutic failure

St John’s Wort,
Rifampicin

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88
Q

Drugs that interact with Phenytoin to antagonise its anticonvulsant effects

A
  • Quinolones
  • Tramadol
  • Mefloquine
  • SSRI’s
  • Antipsychotics
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89
Q

Carbamazepine (narrow therapeutic drug) mode of action

A

Inhibits neuronal sodium channels, stabilises membrane potential and reduces neuronal excitability

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90
Q

What is Carbamazepine used for

A

First line in focal seizures, generalised tonic-clonic seizures. Exacerbates atonic, clonic and myoclonic seizure

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91
Q

Carbamazepine dose therapeutic range

A

4-12mg/L
or
20-50mcg/L

(monitor plasma conc after 1 to 2 weeks)

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92
Q

Symptoms of Carbamazepine Toxicity

A
  • Incoordination
  • Hyponatraemia
  • Ataxia (lack of voluntary muscle movement)
  • Nystamus
  • Drowsiness
  • Blurred vision
  • Arrhythmias
  • Gastro-intestinal disturbances
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93
Q

Side Effects of Carbamazepine Part 1

A
  • blood diseases
    (report signs of infection, fever, sore throat)
  • Hepatotoxicity
    (report signs of liver toxicity, dark urine, jaundice)
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94
Q

Side Effects of Carbamazepine Part 2

A
  • Hypersensitivity reactions
    (antiepileptic hypersensitivity syndrome)(report fever, rash, swollen lymph nodes)
  • Rashes (report rashes)
    (THIA AND CHINESE ALLELE)
  • Hyponatraemia
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95
Q

Dose Limiting or Dose Related side effects of Carbamazepine

A
  • Headaches
  • Ataxia
  • Drowsiness
  • Nausea
  • Vomiting
  • Blurred vision
  • Allergic skin reactions

(M/R forms reduce side effects)

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96
Q

What drugs interact with Carbamazepine to increase plasma concentration

A
  • Cimetidine
  • Macrolides
  • Miconazole
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97
Q

What drugs interact with Carbamazepine reduce plasma conc

A

St John’s Wort
Phenytoin

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98
Q

What drugs interact with Carbamazepine to reduce anticonvolsant effect

A

Quinolones
SSRI’s
Antipsychotics

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99
Q

What drugs interact with Carbamazepine to increase risk of hypontraemia

A
  • Aldosterone Antagonists (spironolactone, Eplerenone)
  • SSRI’s
  • Diuretics
  • NSAID’s
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100
Q

What drugs interact with Carbamazepine to increase risk of hepatotoxicity

A
  • tetracyclines
  • sulfasalazine
  • sodium valproate
  • methotrexate
  • fluconazole
  • alcohol
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101
Q

Carbamazepine reduces the effects of ..

A
  • Warfarin
  • HRT and hormonal contraceptives
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102
Q

Sodium Valproate mode of action

A

weak inhibitor of neuronal sodium channels, stabilises resting membrane potentials and reduces neuronal excitability

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103
Q

Sodium Valproate indications

A

first line in all types of generalised seizures

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104
Q

Sodium Valproate and pregnancy caution

A

Valproate medicines contra-indicated in females of child bearing potential

Unless they are in Pregnancy Prevention Programme or no other alternative

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105
Q

Pregnancy Prevention Programme

A
  • for females with child bearing potential, when other treatments are not tolerated
  • Fully informed of risks associated with pregnancy and valproate
  • Patients must table highly effective contraception
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106
Q

Pregnancy Prevention Programme contraception

A
  • Implants, IUDs, Sterilisation
  • 2 complementary forms of contraception:
    pill + barrier method + regular pregnancy tests
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107
Q

Pharmacist dispensing actions when dispensing valproate related products

A
  • provide valproate PATIENT CARD
  • Remind patient of risks and use of good contraception
  • Try to use whole pack. Must include PIL and warning labels (sticker or box)
  • Ensure they have received patient guide
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108
Q

Side Effects of Sodium Valproate

A
  • Hepatotoxicity

(potentially fatal) (report signs of liver toxicity)
(Discontinue if abnormally prolonged Prothrombin time

  • Blood disease
    (report signs of infection)
  • Pancreatitis
    (report signs of pancreatitis- abdominal pain, nausea, vomiting)
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109
Q

Sodium valproate reaction with these drugs to reduce its anticonvulsant effects

A

Quinolones, SSRIs, Mefloquine

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110
Q

Sodium valproate reaction with these drugs to increase risk of hepatotoxicity

A

Statins, Carbamazepine, Tetracylines, fluconazole, itraconazole, methotrexate, sulfasalazine

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111
Q

Sodium valproate reaction with these drugs, increasing its plasma conc

A

lamotrigine, phenobarbital (other anti-epileptic)

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112
Q

What is status epilepticus

A

Epileptic fits follow one after the other without regaining consciousness

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113
Q

Convulsive status epilepticus treatment

A

IV Lorazepam

(avoid IV Diazepam as it causes thrombophlebitis)

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114
Q

Non-Convulsive status epilepticus treatment

A

If not loss of awareness:

  • use normal oral antiepilpetic drugs

if loss of awareness or failed to respond to oral antiepilpetic drugs:

  • IV Lorazepam
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115
Q

What is a Febrile convulsion

A

Convulsion in child with high temp of 38’C or higher

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116
Q

Febrile convulsion treatment

A

if < 5 mins:
- Paracetamol

if >5 mins:
- IV Lorazepam

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117
Q

Febrile or normal convulsive seizures emergency in community treatment

A
  • Diazepam rectal solution

or…

  • Midazolam Oromucosal Solution

repeat once after 10 to 15 mins if necessary

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118
Q

Anxiety Psychological Symptoms

A
  • Restlessness
  • Worry
  • Fear
  • Difficulty concentrating
  • Irritability
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119
Q

Anxiety Physical Symptoms

A
  • Palpitations
  • muscle aches and tension
  • trembling
  • sweating
  • shortness of breath
  • insomnia
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120
Q

Anxiety treatment

A
  • Benzodiazepines
    (short acting benzodiazepines are better for elderly and for liver impairment, but greater withdraw effects)
  • Beta-Blockers (for autonomic symptoms: Palpitations)
  • Buspirone (5HT1a Agonist)
    (low dependance and abuse, but takes 2 weeks to work)
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121
Q

Other medication to treat Anxiety

A
  • Antidepressants
  • Antiphycotics
  • Meprobamate (license cancelled as serious CNS damage)
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122
Q

Benzodiazepines (Schedule 4 Part 1) mode of action

A

Facilitates and enhances the binding of GABA to the GABAa receptor to cause widespread depressant effect on synaptic neurotransmission

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123
Q

Benzodiazepines examples

A
  • Clobazam (long acting)
  • Diazepam (long)
  • Lorazepam (short)
  • Oxazepam (short)
  • Alprazolam (long)
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124
Q

Benzodiazepines side effects

A
  • Paradoxical increase in hostility aggression
    (range form increased talking to aggression)
  • Overdose can cause:
    Ataxia, Drowsiness, Dysarthria, Nystagmus, Respiratory depression or coma
  • Sedation (avoid alcohol)
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125
Q

Benzodiazepine dependance

A
  • Avoid long term use, and abrupt withdrawal
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126
Q

Benzodiazepine long term use and abrupt withdrawal symptoms

A
  • Toxic psychosis
  • Confusion
  • Delirium
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127
Q

Benzodiazepine withdrawal symptoms

A

increased anxiety, insomnia, weight loss, tremors, sweating, loss of appetite, tinnitus, perceptual disorders

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128
Q

Benzodiazepine withdrawal symptoms occurrence timing

A

Stopping Short Acting Benzodiazepine
- occurs within a day of stopping

Stopping Long acting Benzodiazepines
- occurs within 3 weeks of stopping

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129
Q

Drugs that interact with Benzodiazepines which increase sedation and CNS depressant effects

A

Alcohol, Opioids, antihistamines, antidepressants, barbiturates, antipsychotics

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130
Q

Drugs that interact with Benzodiazepines that increase its plasma conc

A

Amiodarone, diltiazem, macrolides, fluconazole

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131
Q

ADHD symptoms

A
  • hyperactivity
  • impulsivity
  • inattention
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132
Q

ADHD treatment for children (5 years and over)

A

1st Line:
- Methylphenidate

2nd Line:
- Lisdexamfetamine (dexamfetamine for patients intolerable to longer effect profile)

133
Q

ADHD treatment for adults

A

1st Line:
- Methylphenidate

2nd Line:
- Lisdexamfetamine (dexamfetamine for patients intolerable to longer effect profile)

Alternative:
- Atomoxetine

134
Q

Methylphenidate mode of action

A

Potent CND stimulant, increasing dopamine and noradrenaline levels in the brain

135
Q

Methylphenidate side effects

A
  • Appetite loss
  • weight loss
  • insomnia
  • tachycardia
  • raised BP
  • tourette’s syndrome
  • growth restriction in children
136
Q

Methylphenidate monitoring

A

Monitor on starting, dose change and every 6 months:
- Pulse
- BP
- Appetite
- Weight/Height

137
Q

Methylphenidate contra-indications

A

cardiovascular disease , hyperthyroidism, severe hypertension, uncontrolled bipolar, severe depression

138
Q

Methylphenidate prescribing

A

for M/R preparations prescribe using brand

139
Q

Dexamfetamine and Lisdexamfetamine mode of action

A

Potent CNS stimulants, increasing dopamine and noradrenaline levels in the brain

140
Q

Dexamfetamine and Lisdexamfetamine side effects

A
  • appetite loss
  • anorexia
  • tachycardia
  • increased BP
  • tourette’s
  • growth restrictions
141
Q

Dexamfetamine and Lisdexamfetamine monitoring

A

Monitor on starting, dose change and every 6 months:
- pulse
- BP
- appetite
- weight and height
- agression
- depression

allow catch up periods for growth (drug-free periods)

142
Q

Dexamfetamine and Lisdexamfetamine contra-indications

A
  • CVD
  • hyperthyroidism
  • moderate to severe hypertension
  • agitated states
143
Q

Atomoxetine mode of action

A

Noradrenaline reuptake inhibitor causes increased levels of noradrenaline at synaptic cleft

144
Q

Atomoxetine side effects

A
  • Suicidal thoughts (report this behaviour)
  • Haptotoxicity (report signs of liver toxicity)
  • QT prolongation (avoid concomitant use of drugs that increase QT)
145
Q

Atomoxetine monitoring

A

Monitor on starting, dose change and every 6 months:
- Pulse
- BP
- Psychiatric symptoms
- appetite
- weight and height

146
Q

What is bipolar disorder and Mania

A

Characterised by extreme mood swings. A bipolar episode can last several weeks or months

147
Q

Two types of episodes in Bipolar disorder

A

Mania-

feeling high and overactive
(less severe called hypomania)

Depression-

feeling low and lethargic

148
Q

Acute episodes of Mania and hypomania treatment

A
  • Benzodiazepines (short term)
  • Antipsychotics
    (quetiapine, olanzapine, risperidone)

— Add lithium or Valproic Acid added to antipsychotics if response inadequate

149
Q

Prophylaxis of Bipolar disorder (2 years)

A
  • Lithium salts
  • Valproate (sodium valproate or Valproic Acid)
  • Olanzapine
  • Carbamazepine (if unresponsive to other drugs)
150
Q

Contra-indications in Bipolar Disorder

A
  • Do not give antidepressants
  • Rapid cycling Bipolar disorder
  • recent history of hypomania
  • manic episode
  • rapid mood fluctuations
151
Q

Lithium Salts indications

A

Prophylaxis and treatment of mania, hypomania, and depression in bipolar disorder, resistant depression and aggressive or self harming behaviour.

152
Q

Lithium Therapeutic range for lower end for prophylactic treatment / elderly

A

0.4mmol/L to 1mmol/L

153
Q

Lithium Therapeutic range for acute manic episode or patients who have previously relapsed or have subsyndromal symptoms

A

0.8mmol/L to 1mmol/L

154
Q

Plasma Lithium Monitoring

A
  • Blood samples taken 12 hours post dose
  • Monitored every 3 months
  • Monitor more if signifiant intercurrent illness or significant changes to diet or water intake
155
Q

Lithium caution

A

avoid abrupt withdrawal, due to high risk of relapse

156
Q

Symptoms of Lithium Toxicity (REVeNGe)

A
  • R enal Disturbances (polyuria, hypernatraemia)
  • E xtrapyramidal symptoms
    (muscle weakness, fine tremor, ataxia)
  • V isual disturbances
  • N ervous system disturbances
    (confusion, drowsiness, stupor)
  • G astro-intestinal effects
157
Q

If lithium plasma levels exceed 2mmol/L complications can include

A
  • renal failure
  • arrhythmias
  • seizures
  • bp changes
  • circulatory failure
  • coma
  • sudden death
158
Q

Side effects of Lithium Part 1

A
  • Thyroid disorders

(monitor thyroid function tests)
(report hypothyroidism symptoms: weight gain fatigue)

  • Renal Impairment
    (monitor renal function tests)
    (lithium is nephrotoxic)
    (report renal dysfunction)
159
Q

Side effects of Lithium Part 2

A
  • Benign Intracranial Hypertension

(report persistant headaches and visual disturbances)

  • QT Prolongation (cardiac function)
  • Lowers Seizures Threshold
160
Q

Lithium prescribing

A

prescribe by hand

  • different preparations vary in bioavailability
161
Q

Lithium toxicity symptoms

A

hyponatraemia (lower sodium in plasma)

162
Q

Lithium counselling points

A
  • report sings of lithium toxicity
  • maintain salt and water intake
  • lithium can cause drowsiness, so dont drive. Avoid alcohol
163
Q

What is a lithium treatment pack

A

contains a PIL, alert card and record book

  • patient should always carry alert card
164
Q

Lithium OTC interactions

A
  • Ibuprofen
  • Soluble Analgesics
  • Antacids
165
Q

Lithium and pregnancy/breast feeding

A

Lithium is teratogenic
- effective contraception must be used
- toxicity can occur in breastfeeding infants

166
Q

What are extrapyramidal symptoms

A

increased motor tone, changes in the amount and velocity of movement, and involuntary motor activity.

167
Q

What drugs interact with lithium to increase risk of seizures include

A
  • Ciprofloxacin
  • SSRIs
168
Q

What drugs interact with lithium to prolonge the QT interval

A
  • Quinolones
  • SSRIs
  • Marcolides
  • Amiodarone
  • Antipsychotics
  • Theophylline
  • Corticosteroids
  • Loop and Thiazide Diuretics
169
Q

What drugs interact with lithium that reduce renal excretion and what is the complication of that

A
  • ACE inhibitors / ARB’s
  • NSAID’s

This is because lower renal excretion allows more drug to stay in the body, increasing risk of toxicity

170
Q

What drugs interact with lithium to cause hyponatraemia

A
  • Diuretics
  • Antidepressants
171
Q

What drugs interact with lithium that cause higher risk of extrapyramidal symptoms

A
  • Haloperidol
  • Clozapine
  • Metoclopramide
172
Q

What drugs interact with lithium that affect salt balance

A
  • Soluble/effervescent analgesics
  • Sodium containing antacids
173
Q

What drugs interact with lithium that cause an increased risk of neurotoxicity

A
  • Phenytoin
  • Carbamazepine
  • Antipsychotics
  • Amitriptyline
174
Q

What drugs interact with lithium that increase the risk of serotonin syndrome (too much serotonin in brain)

A
  • Sumatriptan
  • SSRI’s
  • Amfetamines
  • St Johns Wort
  • Tramadol
175
Q

What are the psychological symptoms of depression

A
  • Low self esteem
  • Worry/anxiety
  • Suicidal thoughts
176
Q

What are the physical symptoms of depression

A
  • Lack of energy
  • changes in weight/appetite
  • Insomnia
177
Q

Antidepressant mode of action

A

Depression is caused by the under activity of monoamine neurotransmitters. Antidepressants increase monoamine levels at the synapse

178
Q

Depression treatment

A

1st Line:

SSRI’s

2nd Line:

Increase SSRI dose / change SSRi
or…
Mirtazepine

3rd Line:

add another antidepressant class
or…
add augmenting agent (lithium / antipsychotic)

179
Q

2nd Line alternative for depression treatment

A
  • Lofepramine
  • Reboxetine
  • Moclobemide
  • Venlafelaxine
180
Q

Severe Refractory depression treatment

A

Electroconvulsive Therapy

181
Q

Best and most safe antidepressant

A

SSRI

better tolerated, safer in overdose than other classes.

182
Q

What are SSRI’s the least in?

A

Least…
- Sedating
- Antimuscarinic
- Epileptogenic
- Cardiotoxic

183
Q

How long do antidepressants take to work

A
  • at least 2 weeks to work
  • initial worse feeling, increased agitation and anxiety
  • Review ever 1-2 weeks at the start
  • Wait 4 weeks at least to see if treatment failure
184
Q

How long to take antidepressants for

A
  • continue for at least 6 months (12 months in elderly) after remission
  • at least 12 months in anxiety disorder
  • 2 years in recurrent depression
185
Q

Side effects of Antidepressants Part 1

A
  • Hyponatraemia (especially SSRI’s and in elderly)

causes drowsiness, confusion, convulsions

186
Q

Side effects of Antidepressants Part 2

A
  • Suicidal Ideation and Behaviour

(at risk: children, young adults, history of suicide thoughts)

Monitor:
- for suicidal behaviour / self harm
(especially at start or change of dose)

187
Q

Side effects of Antidepressants Part 3

A

Seretonin syndrome

  • Neuromuscular hyperactivity
    (tremors, muscle rigidity)
  • Altered mental state
    (agitation, confusion and mania)
  • Autonomic dysfunciton
    (urination, BP changes, diarrhoea, tachycardia, sweating, shivering)
188
Q

Cautions when switching antidepressant brands

A

washout period required when stopping one antidepressant and starting another class.

This is to avoid serotonin syndrome

189
Q

Washout period for Monoamine Oxidase Inhibitors (MAOIs)

A

2 weeks before switching

(Moclobemide is reversible so doesn’t require washout period)

190
Q

Washout period for Selective Serotonin Reuptake Inhibitors (SSRIs)

A

1 week before switching

(2 weeks for sertraline)
(5 weeks for Fluoxetine)

191
Q

Washout period for Tricyclic Antidepressants (TCAs)

A

1 to 2 weeks before switching

(3 weeks if imipramine or Clomipramine)

192
Q

Antidepressant abrupt withdrawal

A
  • withdrawal symptoms occur within 5 days of stopping
  • risk of withdrawal symptoms increase if taking for more than 8 weeks
  • reduce dose gradually over 4 weeks
193
Q

What two antidepressants have the highest risk of withdrawal reaction

A
  • Paroxetine
  • Venlafaxine
194
Q

Selective Serotonin Reuptake Inhibitors (SSRIs) mode of action

A

selectively inhibits the reuptake of 5-HT from synaptic cleft

195
Q

Examples of SSRIs

A
  • Citalopram
  • Escitalopram
  • Fluoxetine
  • Sertraline
  • Fluvoxamine
  • Paroxetine
196
Q

Which SSRI is safe in MI and unstable angina

A

Sertraline

197
Q

Which antidepressant is licensed for children

A

Fluoxetine

198
Q

Which SSRIs causes QT prolongation

A

Citalopram/Escitalopram

199
Q

SSRI side effects (GASH)

A

G astrointestinal disturbances

A ppetite or weight disturbances

S erotonin syndrome

H ypersensitivty reactions (stop if rashes occur)

200
Q

Other SSRI side effects

A
  • bleeding risk increased
  • QT interval prolongation
  • seizure threshold lowered
  • movement disorders
201
Q

SSRI overdose symptoms

A
  • nausea
  • vomiting
  • agitation
  • tremor
  • drowsiness
  • sinus tachycardia
  • convulsions
202
Q

What drugs interact with SSRIs to increase their plasma concentration

A

Grapefruit Juice (enzyme inhibitor)

203
Q

What drugs interact with SSRIs to increase risk of bleeding

A
  • NSAIDs
  • Anticoagulants
  • Anti-platelets (warfarin)
204
Q

What drugs interact with SSRIs (especially citalopram/escitalopram) to increase risk of prolonged QT interval

A
  • Erythromycin
  • TCAs
  • Sotalol
  • Amiodarone
  • Chloroquine
  • Mefloquine
  • Lithium
  • Quinine
  • Antipsychotics
  • Theophylline
  • Loop/thiazide diuretics
  • corticosteroids
205
Q

What drugs interact with SSRIs to increase risk of hyponatraemia

A
  • Diuretics
  • Desmopressin
  • Carbamazepine
  • NSAIDs
206
Q

What drugs interact with SSRIs to increase risk of serotonin syndrome

A
  • St Johns Wart
  • Amfetamines
  • Sumatriptan
  • Selegiline
  • Tramadol
  • TCAs
  • MAOI
  • Ondansetron
207
Q

Tricyclic Antidepressants (TCAs) and Tricyclic-Like Antidepressants mode of action

A

Inhibits the reuptake of 5-HT and noradrenaline. Also blocks a wide range of receptors M, H1, alpha1/2 and D2

208
Q

Usual Dose of Tricyclic Antidepressants

A

once daily at night (ON)

209
Q

Examples of Tricyclic Antidepressants

A
  • Amitriptyline
  • Clopiramine
  • Dosulepin (dangerous in overdose)
  • Doxepin
  • Trimipramine
  • Imipramine
  • Lofepramine
  • Nortriptylline
210
Q

Examples of Tetracycline Antidepressants

A
  • Mianserin
  • Trazodone
211
Q

What TCAs are used also for neuropathic pain

A
  • Amitriptyline
  • Nortriptylline
212
Q

TCA properties compared to SSRIs

A
  • more sedating
  • more epileptogenic
  • more cardiotoxic
  • more antimuscarinic
213
Q

Side effects of TCAs (TCAS acronym)

A
  • T CAs are more toxic in overdose than SSRIs
  • C ardiac side effects
  • A ntimuscarinic side effects
  • Seizures
214
Q

Other TAC side effects

A
  • hallucinations
  • mania
  • hypotension
  • sexual dysfunction
  • breast changes
215
Q

Examples of antimusarinic side effects

A
  • drug mouth
  • blurred vision
  • constipation
  • tachycardia
  • urinary retention
  • pupil dilation
  • raised intra-ocular pressure, angel closure glaucoma
216
Q

What drugs react with TCAs to reduce plasma concentrations

A

Carbamazepine

217
Q

What drugs react with TCAs to increase plasma concentrations

A

Cimetidine

218
Q

What drugs react with TCAs to increase risk of

A

Diuretics, Desmopressin, Carbamazepine

219
Q

What drugs react with TCAs to increase risk of QT interval prolongation

A

Amiodarone, Sotalol, Antipsychotics, Citalopram/Escitalopram, loop/thiazide diuretics, B2 agonsits, corticosteroids, theophylline

220
Q

What drugs react with TCAs that increases risk of hypotension

A

Alpha-blockers, beta-blockers, ACEI, CCBs, Antipsychotics, Levodopa, NSAIDs, SGLT2 inhibitors (gliflozin), diuretic, Amfetamines, 5-HT1a agonists, ondansetron

221
Q

Monoamine Oxidase Inhibitors (MAOIs)

A

Blocks monoamine oxidase enzymes which leads to accumulation of monoamines

222
Q

Why are MAOIs rarely used

A

due to significant food and drug interactions

223
Q

What are the two types of MAOIs

A
  • Irreversible
  • Reversible
224
Q

Examples of Irreversible MAOIs

A
  • Phenelzine (hepatoxicity more likely)
  • Isocarboxazid (hepatoxicity more likely)
  • Tranylcypromine (greatest stimulant action)
225
Q

Examples of Reversible MAOIs

A
  • Moclobemide (no washout period- short acting)
226
Q

Side Effects of Monoamine Oxidise Inhibitors

A
  • Hepatotoxicity
  • Postural hypotension (discontinue if palpitations or frequent headache)
  • Hypertensive crisis (stop if with headache)
227
Q

Drugs that react with MAOIs to increase chance of hypertensive crisis

A
  • Pseudoephedrine
  • Adrenaline
  • Noradrenaline
  • Levodopa
  • TCAs (potentially lethal)
228
Q

How long can food/drug interactions last after stopping MAOIs

A

2 weeks

229
Q

MAOIs patient counselling

A
  • Avoid foods containing tyramine
  • Eat only fresh food
  • Avoid alcohol/low alcohol drinks
230
Q

Which food contain tyramine

A
  • mature cheese
  • wine
  • pickled herring
  • broad bean pods
  • meat stocks
  • marmite
  • fermented soya bean products
231
Q

What is Benperidol used for?

A

Control of deviant antisocial sexual behaviour

232
Q

What type of drug is Benperidol

A

Butyrophenone antipsychotic

233
Q

What are the four dopamine pathways for schizophrenia

A
  • Mesocorticol Pathways
  • Mesolimbic Pathways
  • Nigrostratal Pathway
  • Tuberofundiular Pathway
234
Q

What symptoms does under activity in the schizophrenic mesocorticol pathway produce

A

Negative symptoms

  • social withdrawal
  • poor hygiene
  • apathy
  • catatoia
235
Q

What symptoms does over actvity in the schizophrenic mesolimbic pathway produce

A

Positive Symptoms
- hallucinations
- delusions
- disorganised speech

236
Q

What symptoms does D2 antagonism in the schizophrenic Nigrostratal Pathway produce

A

Extrapyramidal symptoms
- parkinsonism
- dystonia
- dyskinesia

237
Q

What symptoms does D2 antagonism in the schizophrenic Tuberofundiular Pathway produce

A

Hyperprolactinaemia
- menstruation disturbances
- galactorrhoea
- breast enlargement
- sexual dysfunction

238
Q

Advice on doses of antipsychotic medication above the BNF upper limit

A
  • consider alternatives
  • beware of risk factors (obesity, elderly)
  • consider drug interactions
  • Do ECG to exclude QT prolongation (regular ECG to see if occurs)
  • increase dose once weekly only
  • regular BP, pulse and temp
  • consider high-dose therapy for short term (stop if no improvement over 3 months)
239
Q

How to administer antipsychotics in emergency antipsychotic episode

A
  • IM route
  • IM dose lower than oral dose
240
Q

Prescribing antipsychotics in elderly

A
  • in patients with dementia, increased risk of death and increased risk of stroke
  • Susceptible to postural hypotension and hypo/hyper thermia
  • Initial dose should be half of adult dose
  • not not treat mild-moderate psychotic symptoms
241
Q

Prescribing antipsychotics in patients with learning disabilities. if patient isn’t experiencing psychotic symptoms:

A
  • reduce dose or stop long term treatment
  • review condition after dose reduced/treatment stopped
  • refer to psychiatrist
  • Annual documentation for reasons for continuing antipsychotics if dose not changed or stopped
242
Q

1st Generation Antipsychotics mode of action

A

Blocks post-synaptic Dopamine D2 receptors in the brain

243
Q

What is hyperprolactinaemia

A

abnormally high levels of the hormone prolactin (which stimulates breast milk production during and after pregnancy) in the blood

antipsychotic mediation can have this side effect

244
Q

Different groups of 1st Generation Antipsychotics

A
  • Phenothiazines
  • Butyrophenones
  • Thioxanthes
  • Other
245
Q

How many group of antipsychotics are there in Phenothiazines

A

3

246
Q

Group 1 Phenothiazines (1st generation antipsychotics)

A

Most Sedative

  • Chlorpromazoine
  • Levomepromazine
  • Promazine
247
Q

Group 2 Phenothiazines (1st generation antipsychotics)

A

Least extrapyramidal side effects

  • Pericyazine
248
Q

Group 3 Phenothiazines (1st generation antipsychotics)

A

Most extrapyramidal side effects

  • fluphenazine
  • perphenazine
  • Prochlorperazine
  • Trifuloperazine
249
Q

Examples of Butyrophenones (1st generation antipsychotics)

A

Most extrapyramidal side effects

  • Haloperidol (QV interval prolongation)
250
Q

Examples of Thioxanthenes (1st generation antipsychotics)

A
  • Flupentixol (alerting effect, dont take in evening)
  • Zuclopenthixol (used in aggressive patients)
251
Q

Examples of Other 1st generation antipsychotics

A
  • Pimozide (QT interval prolongation)
  • Sulpiride
  • Loxapine (bronchospasm)
252
Q

2nd generation antipsychotics mode of action

A

Blocks post-synaptic Dopamine D1-D4 receptors and acts on wide range of other receptors
(produce distinct clinical side effects)

253
Q

2nd generation antipsychotics indications

A
  • more able to treat metabolic side effects
  • maybe more effective at treating negative symptoms
254
Q

Examples of 2nd generation antipsychotics

A
  • Amisulpride
  • Aripiprazole
  • Clozapine
  • Lurasidone
  • Olanzapine
  • Paliperidone
  • Quetiapine
  • Risperidone
255
Q

Which 2nd generation antipsychotics causes the most hyperprolactinaemia

A
  • Amisulpride
  • Risperidone
256
Q

Which 2nd generation antipsychotics does not hyperprolactinaemia

A
  • Aripiprazole
257
Q

Which 2nd generation antipsychotic causes the most weight gain and diabetes

A
  • Olanzapine
  • Clozapine
258
Q

Clozapine mode of action

A

2nd generation antipsychotics and is the most effective

259
Q

Clozapine uses

A
  • resistant schizophrenia

(8 to 10 weeks)

if symptoms do not stop, measure clozapine plasma levels before adding second antipsychotic

260
Q

If more than 2 missed doses of clozapine what needs to happen…

A

Treatment needs to be reinitiated by specialist

261
Q

What drugs interact with Clozapine that increase agranulocytosis

A
  • Aminosalicylates
  • Immunosupressants (methotrexate, cytotoxic drugs)
262
Q

What is agranulocytosis

A

a condition in which the absolute neutrophil count (ANC) is less than 100 neutrophils per microlitre of blood

263
Q

Side effects of Clozapine (M)

A

Myocarditis and cardiomyopathy

(stop permanently)

264
Q

What is myocarditis

A

inflammation of the heart muscle (myocardium). The inflammation can reduce the heart’s ability to pump blood.

265
Q

What is Cardiomyopathy

A

where the walls of the heart chambers have become stretched, thickened or stiff, reduce blood pumping

266
Q

Side effects of Clozapine (A)

A

Agranulocytosis and neutropenia (low WCC)

Clozapine patient monitoring service = leucocyte and differential blood count

every week for 18 weeks, then every 2 weeks for 1 year, then monthly

  • avoid drugs that reduce leucopoiesis
  • report influenza like symptoms
267
Q

Side effects of Clozapine (G)

A

Gastrointestinal obstruction

intestinal peristalsis, constipation, paralytic ileus

treat constipation

patient must report constipation

268
Q

What are antipsychotic depot preparations and why are they used

A

Slow, long acting injection

(typically end in deconate)

administered every 1 to 4 weeks by IM

they are used as maintenance therapy to aid compliance

269
Q

Aantipsychotic depot preparations considerations

A
  • should give oral antipsychotic concomitant
270
Q

Do not confuse with other injection preparations

A

IM Haloperidol deconate is used for maintenance

IM Haloperidol is used for rapid control in acute episodes

271
Q

What needs to happen with patients with schizophrenia

A

physical health monitoring every year (including cardiovascular risk assessment)

272
Q

Antipsychotic extrapyramidal symptoms

A
  • Parkinsonism (tremors) (more common in adults and elderly)
  • Akathisia (inner relentlessness (usually after large initial dose)
  • Tardive dyskinesia (rhythmic involuntary movements of tongue, face, jaw)
    (more common in elderly, and long term treatment or high doses)

stop when worm like tongue movements

273
Q

Hyperprolactinaemia signs

A
  • breast symptoms (enlargement, galactorrheoa)
  • reduced bone mineral density
  • menstrual irregularities
  • sexual dysfunction
274
Q

What is the only antipsychotic without the side effect of Hyperprolactinaemia

A

Aripiprazole

275
Q

Antipsychotic metabolic side effects

A
  • hyperglycaemia and sometimes diabetes
  • weight gain
  • Lipid changes

usually with 2nd generation antipsychotics

276
Q

Antipsychotic sexual dysfunciton

A

mostly with haloperidol and Risperidone

277
Q

Mechanisms of Sexual dysfunction

A
  • Blocking D receptors (low libido)
  • Blocking M receptors (arousal disorders)
  • Blocking alpha 1 receptors
    (erectile dysfunction, ejaculation problems)
278
Q

Antipsychotic Cardiovascular side effects side effects

A
  • Tachycardia
  • Arrhythmias
  • Hypotension
  • QT prolongation (most risky= dose above max and IV)

need to have annual CV risk assessment

279
Q

Antipsychotic side effects, hypotension and interference with temperature control

A
  • elderly are especially at risk of falls, hypothermia, hyperthermia
    (initial elderly dose should be half of adult dose
280
Q

What antipsychotics can cause postural hypotension

A

clozapine
chloropromazine
Lurasidone
Quetiapine

281
Q

Antipsychotic drugs side effects, neuroleptic malignant syndrome

A

(FATAL)
symptoms of this:
- muscle rigidity
- change in consciousness
- hyperthermia
- tachycardia
- urinary incontinence

(stop drug immediately)
(lasts 5-7 days after stopping)

282
Q

Treatment of neuroleptic malignant syndrome

A
  • Bromocriptine
  • Dantrolene

(dopamine receptor agonists)

283
Q

Other side effects of antipsychotic drugs

A
  • Antimuscarinic side effects
    (dry mouth, constipation, urinary retention, blurred vision)
  • Blood dyscasisas (monitor with blood cell count)
  • Photosensitivity (at high doses)
  • Sedation
    (avoid alcohol)
284
Q

Caution with chlorpromazine (antipsychotic)

A

avoid direct contact, do not crush tablets and handle solutions with care

285
Q

Pimozide (antipsychotic) caution

A
  • prolongs QT interval
  • monitor ECG before treatment and yearly
  • if prolonged, stop or reduce dose
286
Q

What drugs to not give with Pimozide

A

QT prolongation drugs:
- TCAs
- Antipsychotics
- Antiarrhythmics

Electrolyte imbalance causing drugs:
- Diuretics

287
Q

Side effects of Phenothiazine antipsychotics

A
  • Hepatotoxicity
  • Acute dystonic reactions (muscle spasms, oculogric crisis (upward deviation of eye ball)
    (especially girls and young women)
288
Q

Antipsychotic drug monitoring: every year

A
  • FBC
  • Urea/Electrolytes
  • LFT
  • ECG

(at start then annually)

289
Q

Antipsychotic drug monitoring: at 3 months then yearly

A
  • blood lipids
  • weight

(at start, then 3 months, then yearly)

290
Q

Antipsychotic drug monitoring: 4-6 months then yearly

A
  • Fasting BG level

(at start, 4-6 months, then yearly)

291
Q

Antipsychotic drug monitoring: frequently

A
  • BP

(at start and frequently)

292
Q

What medications interact with antipsychotic drugs to increase QT interval

A
  • Amiodarone
  • Ciprofloxacin
  • Macrolides
  • Quinine
  • SSRIs
293
Q

What medications interact with antipsychotic drugs that increases risk of extrapyramidal side effects

A
  • Metoclopramide
  • Levodopa
294
Q

What medications interact with antipsychotic drugs that increase risk of sedation and CNS depressant effects

A
  • hypnotics (zopiclone)
  • benzodiazepines
  • opioids
  • anti-epileptics
295
Q

What medications interact with antipsychotic drugs to increase risk of hypotension

A
  • anti-hypertensives
  • diuretics
  • nitrates
296
Q

What medications interact with antipsychotic drugs that increases antimuscarinic effects

A
  • TCAs
  • Antihistamines
  • Antimuscarinics (hyoscine)
297
Q

What is Parkinson’s Disease

A

Progressive loss of dopaminergic neurones. Means dopamine is deficient in nigrostriatal pathway. This pathway controls body movement

298
Q

Symptoms of Parkinson’s Disease

A
  • Motor symtoms
    (hypokinesia, bradykinesia, rigidity, postural instability)
  • Non motor symptoms
    (dementia, depression, sleep disturbances, speech and language change, swallowing problems
    (notify DVLA)
299
Q

Parkinson’s disease treatment cautions

A
  • Do not abruptly stop treatment

(can cause acute akinesia and Neuroleptic Malignant syndrome)

  • to treat nausea and vomiting use Domperidone, not metoclopramide
300
Q

What are the 4 types of Dopaminergic drugs

A
  • Levodopa
  • Dopamine Receptor Agonists
  • MAO-B Inhibitors
  • COMT Inhibitors
301
Q

Which dopaminergic drug is associated with more motor complications

A

Levodopa (dopamine precursor)

302
Q

Which dopaminergic drugs are ERGOT-derived

A

Dopamine Receptor Agonists

  • Bromocriptine
  • Cabergoline
  • Pergolide
303
Q

Which dopaminergic drugs are not ERGOT-derived

A

Dopamine Receptor Agonists

  • Pramipexole
  • Ropinirole
  • Rotigotine
304
Q

Which dopaminergic drug is Adjunct to Levodopa

A

COMT Inhibitors

305
Q

Treatment of Parkinson’s disease with Motor symptoms decreasing quality of life

A

1st Line:
Levodopa

306
Q

Treatment of Parkinson’s disease without Motor symptoms decreasing quality of life

A

1st Line:
- Levodopa
- Non-ERGOT derived dopamine-receptor agonists
- MAO-B inhibitors
- COMT inhibitors

307
Q

What is dyskinesia?

A

involuntary, erratic, writhing movements of the face, arms, legs or trunk

308
Q

What is refractory motor fluctuations ‘off’ episodes in Parkinson’s

A

where motor symptoms are more noticeable

309
Q

Treatment of Advanced Parkinson’s Disease (refractory motor fluctuations ‘off’ episodes)

A
  • Apomorphine

(SC) (intermittent injections/continuous infusion)

310
Q

Treatment of Parkinson’s disease (with severe motor fluctuations, hyperkinesia or dyskinesia)

A
  • Levodopa-Carbidopa intestinal gel
311
Q

Treatment of non-responsive Parkinson’s disease

A

Deep Brain Stimulation

312
Q

Levodopa mode of action

A

Levodopa is the amino acid precursor of dopamine and acts by replenishing depleted dopamine levels in the brain

(1st line parkinsons)

313
Q

What is Co-Careldopa

A

Levodopa + Carbidopa

314
Q

What is Co-Beneldopa

A

Levodopa + Benserazide

315
Q

What are Peripheral Dopa-decarboxylase inhibitors

A

blocks conversion of levodopa to dopamine in plasma, allow more levodopa to move through BBB. Dopamine is unable to go there

  • less side effects
  • lower dose required for therapeutic effect
316
Q

Side Effects of Levodopa

A
  • Impulse control disorders (gambling, sexual behaviour)
  • Excessive sleepiness and sudden onset of sleep
    (can’t drive)
  • Motor complications
    (dyskinesia=involuntary muscle movements)
  • End of Dose deterioration with shorter length of benefit
    (M/R forms may help)
317
Q

Dopamine-Receptor Agonists (DRA) mode of action

A

Direct action on dopamine D2 receptors in striatum

(usually associated with more side effects)

318
Q

Side effects of Ergot derived Dopamine-Receptor Agonists (DRA)

Fibrotic Reactions

(Pulmonary)

A
  • Dyspnoea (shortness of breath)
  • Persistant cough
319
Q

Side effects of Ergot derived Dopamine-Receptor Agonists (DRA)

Fibrotic Reactions

(Retroperitoneal) (abdomen area)

A
  • Abdominal pain
  • Tenderness
320
Q

Side effects of Ergot derived Dopamine-Receptor Agonists (DRA)

Fibrotic Reactions

(Pericardial)

A
  • Cardiac failure
321
Q

Side effects of Dopamine-Receptor Agonists (DRA)
overall

A
  • Impulsive control disorders
  • Excessive sleepiness
  • Psychotic symptoms (hallucinations and delusions)
  • Hypotensive reactions in first few days
322
Q

MAO-B inhibitors

A

Inhibits monoamine oxidase B enzymes which are responsible for the breakdown of monoamines: dopamine

323
Q

Examples of MAO-B inhibitors

A
  • Rasagiline
  • Selegiline (metabolises to amfetamine
324
Q

What drugs interact with MAO-B inhibitors that increase risk of hypertensive crisis

A
  • Pseudoephedrine
  • Phenylephrine
  • Oxymetazoline
  • Nasal decongestants
  • adrenaline
  • noradrenaline
  • methylphenidate
  • amphetamines
  • B2 agonists
325
Q

COMT inhibitors mode of action

A

Prevents the peripheral breakdown of levodopa, by inhibiting catechol-O-methyltransferase, allowing more levodopa to the brain

(adjunct to Levodopa)

326
Q

Indication of COMT inhibitors

A

adjunct to levodopa in ‘end-of-dose’ motor fluctuations

327
Q

Examples of COMT inhibitors

A
  • Entacapone (colours urine red/brown)
  • Tolcapone (hepatotoxicity) (report signs of liver toxicity)
328
Q

What drugs interact with COMT inhibitors to increase cardiovascular effects

A
  • Adrenaline
  • Noradrenaline
  • MAOIs

Victor BNF Notes (25 decks)

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