Chapter 4- Nervous System Flashcards
1
Q
Name three anticholinesterase inhibitors used in dementia
A
Donepezil Rivastigmine Galantamine
2
Q
Name the Glutamate receptor antagonist used in more severe dementia
A
Memantine
3
Q
Name 4 antiepileptics that have long half lives and can be given once daily at bedtime
A
Lamotrigine Perampanel Phenobarbital Phenytoin
4
Q
Name 4 antiepileptics in category 1 that are prescribed by brand
A
Phenytoin Carbamazepine Phenobarbital Primidone
5
Q
Drugs that can cause Anti-epileptic syndrome?
A
Carbamazepine
Lacosamide
Lamotrignie
Oxcarbazepine
Phenobarbital
Primodine
Phenyltoin
Rufinamide
(Capsules lack lands once pharmacists poke physical reasons)
6
Q
When can antiepileptic hypersensitivity syndrome start showing symptoms
A
Between 1 and 8 weeks of exposure
7
Q
Symptoms of antiepileptic hypersensitivity syndrome
A
Fever
Rash
Lymphadenopathy
Liver, Haematological and Renal Pulmonary abnormalities
Vasculitis
Multi-organ failure
Frigid Raunchy Little Hampsters Redo Private Antisocial Verant Millions
8
Q
Is there a risk of suicidal thoughts and behaviours with all antiepileptic drugs
A
Yes
9
Q
What interactions occur with antiepileptics
A
Usually as a result of enzyme induction or inhibition
10
Q
How do we withdraw antiepileptics?
A
All Antiepilepcitcs are withdrawn gradually and under supervision. Avoid Abrupt withdrawal particularly in barbituates and benzodiazepines as this can cause severe rebound seizures
11
Q
Which antiepileptic has the highest teratigenicity risk and how do we address this?
A
Valproate has the highest teratogenic risk. Women should be on a PPP. Pregnancy Prevention Programme. Ideally it shouldnt be use in women that are pregnant
12
Q
Topiramate carries with it an increase risk of what if used in the first trimester of pregnancy?
A
Cleft palate
13
Q
Women taking antiepileptics meds are advised to take what before conception and during first trimester and why?
A
Folate supplementation or there will be neural tube defects
14
Q
The concentration of antiepileptic drugs in the plasma can change during preganancy - doses of which 3 antiepileptics should be adjusted on the basis of plasma drug conc
A
Carbamazepine
Lamotrigine
Phenyltoin
(Cows lack Pills)
15
Q
What should be monitored for pregnant women taking topiramate or levetiracetam
A
Fetal growth
16
Q
What injection at birth minimises the risk of neonatal haemorrhage associated with antiepileptics
A
Injection of vitamin K helps minimise the risk of neonatal haemorrhage associated with ALL antiepileptics
17
Q
Name three antiepileptics with an established risk of drowsiness in breast fed babies and that should be used with caution as a result
A
Benzodiazepines
Primidone
Phenobarbital
(BPP) Breast Protein Power
18
Q
Carbamazepine may exacerbate what types of seizures and therefore should not be used?
A
“MATA”
Myoclonic
Absence
Tonic
Atonic
19
Q
First line treatment option for absence seizures?
A
Ethosuximide
20
Q
True or false: lamotrigine can exacerbate myoclonic seizures
A
True
21
Q
True or false: valproate decreases the plasma concentration of lamotrigine
A
False - it increases it!
22
Q
What’s responsible for the antiepileptic effects of primidone
A
It’s converted to phenobarbital
23
Q
Antiepileptic licensed for adjunctive treatment of seizures in Lennox-gastaut syndrome
A
Rufinamide
24
Q
Sodium valproate has widespread metabolic effects and monitoring of what is therefore essential
A
LFT FBC
25
Treatment options for seizures lasting longer than 5 minutes
IV lorazepam IV diazepam
26
There is a risk of what syndrome in patients with HLA-B\*1502 allele for carbamazepine
Stevens-Johnson syndrome
27
For carbamazepine what's the plasma concentration for optimum response
4-12mg/litre (20-50micromol/litre)
28
Name three things in the rosemont brand of gabapentin oral solution that exceed the WHO recommended limits if high doses are required
Propylene glycol
Acesulfame K (sweetner)
Saccharin sodium (sweetner)
29
Symptoms of phenytoin toxicity
Nystagmus
Ataxia (lack of coordinated muscle movement)
Confusion
Hyperglycaemia
Slurred speech
Diplopia (seeing double)
**NACHSD**
30
Name the prodrug of dexamfetamine
Lisdexamfetamine
31
The usual total plasma phenytoin concentration for optimum response is what?
10-20 mg/litre (or 40-80micromol/litre)
32
If you take topiramate in the first trimester of pregnancy what is there an increased risk of?
Cleft palate
33
Topiramate has been associated with what?
Associated with acute myopia with secondary angle-closure glaucoma
34
Plasma phenobarbital concentration for optimum response is what?
15-40 mg/litre (60-180 micromol/litre)
35
What can be used in palliative care to reverse the effects of midazolam
Flumazenil
36
Should modified release preparations of methylphenidate be prescribed by brand?
Yes
37
Symptoms of overdose of Amphetamines
Wakefulness
Excessive activity
Paranoia
Hallucinations
Hypertension
....Followed by exhaustion Convulsions Hyperthermia Coma
38
Long term use of lithium has been associated with what and requires what as a result
Thyroid disorders and mild cognitive and memory impairment - monitor thyroid function every 6 months
39
When should levels be taken for lithium and what's the targets?
12 hours after dose Target: 0.4-1mmol/litre For acute episodes of mania the target is: 0.8-1mmol/litre
40
Drug interaction if introducing ACEI, NSAID or diuretic with lithium?
ACE + NSAID + Diuretic + Lithium = Renal impairment
41
Symptoms of lithium toxicity
Hypothyroidism Renal dysfunction Intracranial hypertension (headache + visual disturbances)
42
During the first few weeks of antidepressant treatment there is an increased risk of what?
Agitation Anxiety Suicidal ideation
(AAS)
43
What class of antidepressant is first line and why?
SSRIs - better tolerated and safer in overdose
44
What does St. John's wort do to metabolising enzymes?
Induces drug metabolising enzymes
45
True or false: elderly patients may take longer to respond to antidepressants
True
46
Antidepressant therapy (particularly SSRIs) have been associated with hyponatraemia and can make what symptoms develop?
Confusion Drowsiness Convulsions (hence lowers seizure threshold when taken with antiepileptics)
**CDC = hyponatremia**
47
Characteristics of serotonin syndrome fall into what three categories
Neuromuscular hyperactivity Autonomic dysfunction Altered mental state
48
Symptoms associated with neuromuscular hyperactivity in serotonin syndrome
Myoclonus
Rigidity
Tremor
Hyperreflexia
Clonus
**MR. THC**
Are symptoms of what?
49
Symptoms associated with autonomic dysfunction in serotonin syndrome
Tachycardia
BP changes
Hyperthermia
Diaphoresis (Sweating)
Shivering
Diarrhoea
50
Symptoms associated with altered mental state in serotonin syndrome
Mania Agitation Confusion
51
Name the three less sedating TCAs & Related antidepressants
Imipramine Lofepramine Nortriptyline
52
True or false: low gastric pH causes reduced absorption of the paroxetine oral suspension
False - a high gastric pH reduces absorption of paroxetine oral susp
53
Name the group 1 phenothiazine derivative antipsychotics and what are their side effects
Chlorpromazine Levomepromazine Promazine Pronounced sedative Moderate antimuscarinic Moderate extrapyramidal
54
Name two butyrophenones and which class of the phenothiazine derivatives do they resemble?
Benperidol Haloperidol Group 3!
55
Name a diphenylbutylpiperidine
Pimozide
56
Name a substituted benzamide
Sulpiride
57
Aripiprazole reduces prolactin - why?
It's only a dopamine receptor partial agonist
58
Which antipsychotics are most likely to cause symptomatic hyperprolactinaemia
Risperidone Amisulpride & First generations
59
Symptoms of hyperprolactinaemia
Sexual dysfunction
Reduced bone mineral density
Breast enlargement
Galactorrhoea
60
Antipsychotics have been associated with what cardiovascular side effects
Tachycardia
Arrhythmias
Hypotension
Prolong QT
61
**All antipsychotics can cause weight gain and hyperglycaemia**- which ones are of particular concern with causing diabetes?
Clozapine
Olanzapine
Quetiapine
Risperidone
CiROQ
62
Name a rare but potentially fatal side effect of all antipsychotic drugs and how long can it last for after discontinuation of the drug
Neuroleptic malignant syndrome 5-7 days
63
True or false: first generation antipsychotics are better at treating the negative symptoms of schizophrenia
False! Second generation are better
64
True or false: first generation antipsychotics are less likely to cause diabetes than the second generation
TRUE DAT
65
Haloperidol dose adjustments when?
If smoking started or stopped during treatment
66
Monitoring requirements for pimozide (1st generation antipsychotic)
ECG- there's been reports of unexplained sudden death - caution QT prolongation
67
What's the name given to the phenothiazines that explains the facial and skeletal muscle spasms and ocugyric crises
Acute dystonic reactions
68
True or false: phenothiazines are hepatotoxic
True dat
69
Is BP monitoring mandatory for sulpiride?
No- does not affect blood pressure as much as other antipsychotics
70
Name four first generation antipsychotic depot injections
Flupentixol decanoate Fluphenazine decanoate Haloperidol decanoate Zuclopenthixol decanoate
71
How can you treat hypersalivation side effect of clozapine
Hyoscine hydrobromide- aslong as patient not at risk of addictive antimuscarinic side effects of hyoscine and clozapine combined
72
Treatment options for muscle cramps in motor neurone diseases
Quinine Baclofen Tizanidine Dantrolene Gabapentin
73
Name three non ergot derived dopamine agonists used in Parkinson's disease
Pramipexole Ropinirole Rotigotine
74
Name three ergot derived dopamine agonists used in Parkinson's
Bromocriptine Cabergoline Pergolide
75
Why are ergot derived dopamine agonists used to a less extent than non ergot derived DA in Parkinson's
Risk of fibrotic reactions
76
What is apomorphine
Potent dopamine receptor agonist used in advanced Parkinson's disease to help with off periods
77
Name two dopa decarboxylase inhibitors
Benserazide Carbidopa
78
Name two MAO type B inhibitors used in Parkinson's
Rasagiline Selegiline Safinamide
79
When would you introduce COMPT inhibitors in Parkinson's disease
In patients on levodopa + dopa decarboxylase experiencing end of dose motor fluctuations
80
When adding COMPT inhibitors to Parkinson's meds regimen what may need to be reduced
Levodopa dose by around 10-30%
81
Name three COMT inhibitors
Entacapone
Opicapone
Tolcapone
are all COMT inhibitors
82
Why is there restrictions from the MHRA on the use of domperidone
It's associated with a small increased risk of serious cardiac side effects
83
What are the MHRA restrictions on domperidone
Only indicated for N&V lowest effective dose for max one week .
Contraindicated in cardiac conditions or at risk of QT prolong and in combo with CYP3A4 inhibitors.
Not in severe hepatic impairment Recommended dose in over 12 and over 35kg is 10mg up to TDS
Recommended dose in children under 35kg is 250mcg/kg up to TDS
84
MHRA recommendations on metoclopramide
Particular indications Max 5 days treatment 10mg up to TDS - max daily dose 500mcg/kg IV slow plus over 3 mins
85
What's aprepitant and fosaprepitant
Neurokinin receptor antagonists used for nausea and vomiting - fosaprepitant is the prodrug of aprepitant
86
MHRA warning about promethazine
Children under 6 years should not be given OTC cough and cold meds containing promethazine
87
Pain in sickle cell disease
Paracetamol Ibuprofen Codeine/dihydrocodeine Morphine/diamorphine
88
What painkiller should be avoided in sickle cell disease and why?
Pethidine - accumulation of a neurotoxic metabolite which can precipitate seizures
89
Three drugs often adequate in dental pain
Paracetamol Ibuprofen Aspirin
90
Side effects of Opioids
Nausea & vom Severe constipation Drowsiness Resp depression Dependence
91
Which has longer duration of action: buprenorphine or morphine?
Buprenorphine
92
Sublingual buprenorphine lasts how long
Subutex Lasts 6-8hrs
93
Benefit of diamorphine in palliative care
Greater solubility means smaller injection volume, less nausea and less hypotension
94
Fever/increased heat to buprenorphine patch can cause what
Increased absorption
95
Methadone/buprenorphine for opioid dependence - supervised consumption should be for how long
3 months
96
Max dose of codeine in adults
240mg (60mg QDS)
97
Codeine is contraindicated in patients who are what metabolisers
Ultra rapid metabolisers (CYP2D6 ultra rapid metabolisers)
98
Why are dispersive or effervescent analgesic preferred in migraine?
Peristalsis is reduced therefore reducing absorption
99
Name the short acting Z drugs used for insomnia
Zaleplon Zolpidem Zopiclone
100
Name three shorter acting benzodiazepines with little or no hangover effect
Loprazolam
Lormetazepam
Temazepam
101
Caution/further information for benzodiazepines
Paradoxical effects - increase in hostility and aggression
102
Three drugs used in narcolepsy
Sodium oxybate Pitolisant Modafinil
103
Drug used in alcohol withdrawal
Chloridazepoxide
104
Three drugs used in alcohol relapse prevention
Acomprosate Naltrexone Disulfiram (2nd line)
105
Drug used to reduce alcohol intake
Nalmefene
106
Two drugs used to treat nicotine dependence
Bupropion Varenicline
107
Can you use nicotine replacement therapy and bupropion or varenicline together?
It's not recommended
108
Smoking induces what enzyme and which drugs should therefore be monitored
**CYP1A2**
Theophylline
Cinacalcet
Ropinirole
Antipsychotics (cloz, olanz, chlorpromazine, haloperidol)
109
Which is more sedating- methadone or buprenorphine?
Methadone is more sedading than buprenorphine
110
How long does it take methadone to reach steady state for patients on a stable dose and why?
3-10 days due to long half life
111
Signs of neonatal withdrawal from opioids
High pitched cry Rapid breathing Hungry but ineffective suckling Excessive wakefulness Hypertonicity Convulsions
112
MHRA/CHM advice with varenicline for nicotine dependence
Suicidal behaviour - discontinue if they develop agitation, depressed mood, suicidal thoughts
113
Hypnotics in elderly can cause what
Ataxia Confusion Falls
114
Long term treatment of bipolar disorder should continue for how long after the last manic episode
At least 2 yrs (5 yrs in those at risk of relapse)
115
Name the MAOI that has the greatest stimulant action and therefore causes increased risk of hypertensive crisis
Tranylcypromine
116
Which two MAOIs are more likely to cause hepatotoxicity than tranylcypromine
Phenelzine Isocarboxazid
117
4 antipsychotics with increased risk of hyperglycaemia and weight gain
Clozapine Olanzapine Quetiapine Risperidone
118
Two first generations that have less risk of causing diabetes
Fluphenazine Haloperidol
119
Of the second generations which are less likely to cause diabetes &a weight gain
Amisulpride Aripiprazole
120
For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer's product
Carbamazepine / Phenobarbital / Phenyltoin / Primidone
CPPP
121
For these drugs, the need for continued supply of a particular manufacturer's product should be based on clinical judgement and consultation with the patient. What other factors do we take into account?
We Consider Factors such as Seizure frequency and Treatment history.
Drugs are:
Valproate / Lamotrigine / Perampanel / Clozabam / Oxcarbazepine / Topiramate
**CLOT P**
122
For these drugs, its usually unnessary to maintain a manufacturers product unless there's specific conserns such as what?
Usually its ok to change unless the patient has anxiety. these drugs are
GELLT
Gabapentin.. Ethosuximide.. Lacosamide. Levetiracetam... Tiagabine
123
Whats special about Benzodiazepines, Primodine and Phenobarbital?
They metabolise slowly in neonates and can cause drowsinessand so caution is neseccary
124
How should antiepiletic mothers monitor their breastfeeding infants?
Monitor Breastfeeding infants for adequate weight gain/ developmental milestones/ feeding difficulties and over sedation
125
What are Focal Seizures?
What are your first line options for treating newly diagnosed focal seizures? What's next if not tolereated?
Result from abnormal activity in one part of the brain.
**Can be with loss of consciousness**
**Can be without loss of consciousness :**These seizures may also result in the involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.
Carbamazepine and Lamotrigine = First Line for newly diagnosed focal seizures
If it's not tolerated, treat with Oxcarbazepine/ Sodium Valproate / Levetiracetam
126
What is the Signs of a Tonic-Clonic Seizure? What is first line treatment for Tonic-Clonic seizures? and what to do if thats not tolerated?
most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or **biting your tongue.**
Sodium Valproate i n newly diagnosed tonic-clonic seizures (Except in females). Lamotrigine and Carbamazepine are the alternatives, but it may exacrbate an absence seizure.
127
What is an Absence seizure and First line of treatment in an absence seizure?
often occur in children and are characterized by staring into space or by subtle body movements, such as eye blinking or lip smacking. **Very brief loss of consciousness.**
Ethosuximide OR Sodium Valproate (Except in pregnant women that are pre-menopausal). Ethosuximide can be used as adjunt therapy if its not effective
128
Symptoms of Epilepsy?
sweaty palms too
129
Common / Very Common ADRS of Carbamazepine?
Carbamazepine :
GI upset
Neurological effects eg dizziness and ataxia.
Mild skin rash.
**antiepiletic hypersensitivity syndrome**.
Odema and hypernatraemia
130
Whats key about Phenyltoin?
Its a high risk drug of a narrow therapeutic index.
Binds to neuronal Na+ channels in their inactive state and prolongs activity.
It is a highly protein bound drug, and there is a reduced plasma free-drug concentration in:
**Pregnancy, Children (Neonates \<3 months), elderly and in liver failure.**
They show early signs of toxicity.
131
Tell me about switching Phenytoin products?
132
Side Effects of Phenyltoin?
Other than the image:
Phenytoin induces Vitamin D metabolism. **Consider Vit D supplements.**
Hepatotoxicity. Signs: **Dark** Uring, N & V. *Jaundice*
133
what unfortunate thing can all antiepileptic drugs create the idea of?
suicide
134
Tell me about injected IV Phenytoin and Fosphenytoin
135
Phenytoin interactions
136
Carbamazepine use, therapeutic range and signs + **signs and symptoms of Toxicity**?
137
Side effects of Carbamazepine and what preparations reduce side effects?
Modified preparations reduce side effects in the elderly
138
Drug interactions of Carbmazepine
139
What are your cognitive and non cognitive symptoms in Dementia?
140
Drug Management in Dementia and when to stop etc?
141
Which **Antepileptics** are enzyme inducers and which are inhibitors?
142
Management of non cognitive symptoms in dementia?
143
What are they key interactions of valproate?
144
Whats the three types of Status Epilepticus?
145
What classes as a epileptic medical emergency in the local community and how do we treat it
146
Give me a Low-Down of the Physical and Psychological symptoms of anxiety
147
What drugs are given in anxiety?
148
How do BDZ work and what are its clinical manifestations?
149
Side effects of BDZ and Use of BDZ?
150
BDZ dependence what are the signs? and can we stop suddenly?
Onset time of symptoms?
How do we withdraw?
151
what drugs interact with BDZ?
152
types of epilepsy ND treatments for epilepsy
153
What is Parkinsons in terms of signs and what is the available treatments for nausea and vomiting. Can i stop suddently?
154
Symptoms of Parkinsons when its severe
155
156
how do you treat parkinsons in first line and how is it dosed to avoid?
157
Levodopa side effects
excessive sleep.
158
what is first line in patients experiencing motor symptoms in parkinsons that **dont** affect quality of life?
Non - ergot derived d2 antagonists such as pamiprexole
Rotigotine
OR given as an adjunct to levodopa
159
warnings assocaited with Domperidone?`
160
opiates side effects
