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Chapter 4- NS Flashcards

1
Q

What is dementia

A

Dementia is not a disease it is a progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms such as memory loss problems with reading and communication and a change in personality

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2
Q

What is the most common type of dementia

A

Alzheimer’s disease

Other types include 
Vascular disease (reduced blood flow)
Lewy body 
Mixed dementia
Frontotemporal dementia
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3
Q

What is the aim of treatment of dementia

A

To promote independence maintain function and manage symptoms

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4
Q

Why is minimising the amount of Antimuscarinic drugs a patient with dementia is on be suitable

A

They increase cognitive impairment so it helps management of cognitive symptoms

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5
Q

What is the first line treatment in newly diagnosed patients with mild to moderate Alzheimer’s disease

A

Acetylcholinestrease inhibitors such as donepezil, galantamine or rivastigmine

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6
Q

What is the drug of choice in patients with severe Alzheimer’s disease or when AceE is not tolerated/ contra-indicated

A

Memantine

AChE inhibitors are contraindicated

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7
Q

What medication is indicated for mild to moderate dementia with Lewy bodies

A

AChE inhibitors:
Donepezil or rivastigmine

Then galantamine if those don’t work

Menantamine if acetylcholinestrase inhibitors are not tolerated

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8
Q

When are acetylcholinestrase inhibitors and memantine NOT recommended

A

In patients with frontotempral dementia or cognitive impairment cause by multiple sclerosis

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9
Q

When are antipsychotics indicated for patients with dementia

A

If they are at risk of harming themselves or others if they are experiencing agitation hallucinations or delusions that are causing them severe distress

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10
Q

MHRA ALERT

Why are antipsychotics cautioned in the use of elderly patients with dementia

A

Studies show it has an increased risk of stroke and a small increased risk of death

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11
Q

Name the anticholinesterases that are centrally acting

A

Donepezil
Rivastagmine
Galantamine

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12
Q

Name a dopaminergic NMDA glutamate receptor agonist drug

A

Memantine

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13
Q

What are the symptoms of antiepileptic hypersensitivity syndrome

A

Fever rash and lymphadenopathy are most common

Other symptoms include liver dysfunction, haematological, renal pulmonary abnormalities

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14
Q

Why is monotherapy preferred an epileptic treatment

A

Combination therapy increases the risk of interactions and side-effects

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15
Q

Can epileptic patients drive

A

Yes if they have been seizure free for at least one year
No history of unprovoked seizures
Or if they have only suffered from sleeping seizures for three years

They have a 6 month driving ban if
Medication is being changed or withdrawn and they’ve been seizure free for that time

5 year ban for lorries or vehicles with passengers

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16
Q

Are antiepileptic safe to use in pregnancy

A

Many are teratogenic so advice should be seeked from specialised

In planned pregnancy it is best to stop treatment in the first trimester

In unplanned pregnancy it is best to continue antiepileptic treatment as usual

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17
Q

What anti-epileptic drug has 30-40% chance of severe disorder in pregnancy

A

Sodium valproate

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18
Q

What is the first line treatment for focal (partial) seizures with or without a secondary generalisation

A

Carbamazepine or lamotrigine

Oxcarbazepine, sodium valproate and levetiracetam may be used if the first two fail

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19
Q

What’s the first line treatment for generalised tonic-clonic seizure

A 
Sodium valproate (or carbamazepine)
Lamotrigine is an alternative choice
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20
Q

First line treatment for generalised absence seizures

A

Ethosuximide or Sodium valproate

Lamotrigine is a suitable alternative if they fail

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21
Q

First line treatment for generalised myoclonic seizures

A

Sodium valproate

Topiramate and levetiracetam are options if sodium valproate fails

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22
Q

What signs and symptoms should people on carbamazepine look out for

A

Infection, Blood, liver and skin disorders

Fever rash mouth ulcers bleeding or bruising

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23
Q

What signs and symptoms should patients on lamotrigine look out for

A

Bone marrow failure (anaemia bruising and infection)

Serious skin reaction

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24
Q

What signs and symptoms should patient on valproate as an epileptic look out for

A

Liver toxicity, blood disorder and pancreatitis

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25
What should be routinely monitored when using valllproate
Liver function | full blood counts (causes low platelets)
26
What’s the phenytoin drug level target And for neonates
10-20mg/L (40-80micromol/L) Neonates: 6-15mg/L
27
What’s the symptoms of phenytoin toxicity
Double vision, slurred speech, ataxia, confusion, hyperglycaemia and nystagmus
28
What’s important about prescribing phenytoin
It’s brand specific so should be prescribed by brand
29
What a tonic seizures
Generalised seizure so affects most the brain. Body becomes stiff/ flexed and you can fall backward Most often occur during sleep
30
What is an atonic seizure
Generalised seizure with Sudden loss of muscle tone so that the child goes limp and can fall frontwards to the ground
31
What’s a tonic clonic seizure
Generalised seizure that affects the entire brain | Body becomes still, fall backwards followed by aggressive phase
32
What is a myoclonic seizures
Generalised seizure Usually causes abnormal Movements on both sides of the brain at the same time resulting in short muscle twitches
33
What’s a partial focal seizure
Occurs when the electrical activity remains in a limited area of the brain and sometimes turn into generalised seizure which affects the whole brain
34
Name the category one antiepileptic drugs (CP3)
Phenytoin Carbamazepine Phenobarbital Primidone
35
Name the category two antiepileptic drugs
``` Valproate Lamotrigine Perampanel Clobazam Topiramate Zonisamide ```
36
Name the category three antiepileptic drugs
``` Levetiracetam Lacosamide Tiagabine Gabapentin Vigbatrin ```
37
What seizures should you not use pregabalin for
Tonic, atonic or absent seizures
38
What’s the interaction between lamotrigine and valproate
Valproate increased lamotrigine concentration
39
Which antiepileptic is used for only over 18 years
Retigabine
40
Which antiepileptic may be sedative and can develop tolerance
Phenobarbital or primidone
41
Most antiepileptics are given BD which ones have a long half life and I’ll given once a day
Lamotrigine Phenobarbital Phenytoin Parampanel
42
Do younger children metabolise antiepileptics more rapidly or slower
More rapidly so higher doses may be needed
43
What’s the optimise response range levels for carbamazepine
4-12mg/L
44
What are the side-effects does phenytoin have that might affect social life of a person
Acne Gingival hypertrophy Hypersensitivity reaction (fever, rash)
45
What side effect is the antiepileptic drug topiramate associated with
Myopia with secondary angle-closure glaucoma
46
What do you do when a patient is having status epilepticus
Position patient to avoid injury, support respiration and provide oxygen Maintain BP, correct hypoglycaemia Parenteral thiamine given it alcohol abuse suspected Pyridoxine given it status epilepticus thought to be caused by deficiency If seizure longer than 5 minutes give IV lorazepam (IV diazepam has risk of thrombophlebitis) Clonazepam can be an alternative Phenytoin or fosphenytoin can be given after initial treatment
47
What are first line antidepressants and why
SSRI- they are generally the safest. Less sedating, fewer antimuscarinic and cardio toxic effects TCA have more pronounced side effects and a more dangerous level of toxicity in overdose MAOIs have serious interactions with other drugs and some food (can’t have drink, cheese, meat)
48
Which SSRI is given for anxiety
Buspirone
49
What’s the MHRA alert for the use of benzodiazepines and opioids
The use together can produce additive CNS depressant effects increasing the risk of sedation, respiratory depression, coma and death.
50
If a patient is prescribed benzodiazepines and opioids what should be monitored?
Sedation and respiratory depressant effects
51
What are the hypotonic, sedative and anxiolytic benzodiazepams used for anxiety (Clue: A D C O)
Alprazolam Chlordiazepoxide Diazepam Oxazepam
52
What is ADHD (attention deficit hyperactivity disorder)
Behavioural disorder characterised by hyperactivity, impulsivity and inattention. Which can lead to functional impairment such as psychological social educational or occupational difficulties. (Ranges from hyperactive to inattentive)
53
Aim of treatment for ADHD
Reduce functional impairment Reduce severity of symptoms Improve quality of life
54
What are the first line stimulant treatments for patients with ADHD for patients >5 years
Centrally acting sympathomimetics Methylphenidate (first line) Or (Lis)Dexamfetamine For 6 weeks and if no longer improvement try the other one
55
What should be monitored when CNS stimulants are prescribed for ADHD
``` Pulse Blood pressure Appetite Weight Height Psychiatric symptoms ``` All monitored every 6 months
56
What schedule are the centrally acting sympathomimetics used for ADHD
Schedule 2
57
When should anti depressants be avoided in patients in bipolar disorder and mania?
In patients with rapid cycling bipolar disorder A recent history of hypomania Manic episode Rapid mood fluctuations
58
Why should benzodiazepines not be used for long periods of time in patients with bipolar disorder and mania?
Risk of dependence
59
When are carbamazepine used in bipolar disorder and mania?
In patients unresponsive to a combination of other prophylactic drugs Used in patients with rapid-cycling manic depressive illness
60
What is valproate used for in bipolar and mania
Valporic acid and sodium valporate are widely used for the treatment of manic episodes associated with bipolar disorder
61
When is lithium indicated for use in bipolar and mania disorder
MOOD STABILISER Prophylaxis and treatment of mania, hypomania and depression in bipolar disorder and unipolar disorder Also used for the treatment of aggressive and self harming behaviour
62
What should you caution with the use of benzo
Hepatic impairment as it can lead to coma
63
How do first generation antipsychotics work
They block the dopamine receptor in the brain
64
Common side effects of first generation antipsychotic
EPSE- extra pyramidal side effects - Parkinson’s symptoms (such as tremor) - Dystonia (abnormal face and body movement) - Akathisia (restlessness) - Tardative dyskinesia (involuntary movement of the jaw face and tongue) Raised prolactin (dopamine inhibits prolactin release and antipsychotics block dopamine receptors)
65
Examples of first generation antipsychotics
Chlorpromazine Haloperidol Flupentixol
66
How do Second generation antipsychotics work
They act on a range of receptors on the brain
67
Examples of second generation antipsychotics
Aripipazole Clozapine Olanzapine Risperidone
68
Which group of people should antipsychotics be used with caution
``` Cardiovascular disease Parkinson’s Epilepsy Depression Respiratory disease ```
69
What should patients on antipsychotics be told to avoid
Sunlight
70
Which antipsychotic doesnt have hyperprolactinaemia as a side effect and why?
Aripiprazole It’s a partial dopamine receptor agonist while all other antipsychotics are dopamine antagonists Dopamine inhibits prolactin release
71
What should be monitored for a patient on antipsychotics
FBC, urea, electrolytes, LFTs | Lipid, weight, prolactin, blood pressure, blood glucose
72
Causation for chlorpromazine dispensing (antipsychotic)
Tablets should not be handled
73
What is clozapine indicated for and what needs to be monitored
Schizophrenia Monitor WBC
74
Why should lithium be prescribed by brand name
It has a narrow therapeutic index and the bioavailability of preparations vary
75
When can toxic effects present with lithium use What’s the therapeutic effect
Above 1.5 mol/L 0.6-1.2
76
Why should concurrent use of lithium and diuretics (especially thiazide) be avoided
Lithium toxicity is worsened by sodium depletion
77
What is long term use of lithium linked to
Thyroid problems Should be monitored every 6 months
78
Why’s it important to prescribe valproate by brand name
It includes sodium valproate and valporic acid which have different indications Valporic acid- mania in bipolar disorder and migraine prophylaxis Sodium valproate- epilepsy and other types of mania
79
If the response to antipsychotics is not adequate in acute episodes of mania and hypomania , what can be added
Lithium or valproate
80
Effects of increased prolactin from antipsychotic use
Sexual dysfunction Breast enlargement Milk production from women (galactorrhoea)
81
Which anytipsychotics are cautioned in diabetes and why?
Clozapine olanzapine Quetiapine and respiridone Can cause hyperglycaemia
82
Which antipsychotics can cause weight gain
Clozapine and olanzapine
83
What are the signs of neuroleptic malignant syndrome and what is is causes by
Hyperthermia Muscle rigidity Sweating Urinary incontinence Rare but serious side effect of antipsychotics and donepezil
84
What is usually the first benefit of antidepressant treatment
Improvement of sleep
85
What treatment should be given for mild depression
Psychological therapy
86
What are the classes of antidepressants
Tricyclics (TCA) Selective serotonin reputable inhibitor (SSRI) Monoamine oxidase inhibitor (MAOI)
87
Safest antidepressant for a patient who has had an MI or has unstable angina
Sertraline
88
What is St. John wort
A herbal medicine sold for treating mild depression
89
What is a common side effect of all antidepressant especially SSRI
Hyponatraemia
90
What signs should you look out for in hyponatraemi
Drowsiness Confusion Convulsion
91
The 3 major symptoms of serotonin syndrome
1. Neuromuscular hyperactivity (tremor, hyperreflexia, rigidity) 2. Autonomic dysfunction (tachycardia, BP changes, hyperthermia, shivering) 3. Altered mental state (agitation, confusion, mania)
92
Acute anxiety (<4 weeks) is usually managed by benzodiazepines, what can long term anxiety be managed by
``` Antidepressant (SSRI then SNRI) Pregabalin can be tried if this fails Beta blocker Barbiturates Buspirone ```
93
After how long of using an antidepressant can it be deemed ineffective
4 weeks
94
How long should antidepressant be carried on for
6 months in a otherwise healthy patient | 2 years in patients with history of recurrent depression
95
When should an augmenting agent (lithium, antipsychotic) be added to a depressive treatment
If the fail to respond to an SSRI, try increase the dose or another or Mirtazapine (alpha-2 adrenal receptor antagonist) Failure to respond to that and other classes like SNRI (Venlafaxine) and TCA Then an augmenting agent may be indicated
96
Apart from depression what else can SSRI be used for
Panic disorder, OCD, social anxiety disorder.
97
Examples of tricyclics and how they work
Amitriptyline Nortriptyline Inhibit the re uptake of both serotonin and noradrenaline
98
What other uses can TCA have other than depression
Anxiety and agitation | Neuropathic pain
99
Common side effects of TCA drugs
``` Antimuscarinic effects like Dry mouth Blurred vision Urinalysis retention Constipation ```
100
Drug Interactions with amitriptyline
Warfarin- increase or decrease INR | interact with antiepileptic
101
Examples of SSRI antidepressant
Citalopram Fluoxetine Paroxetine Sertraline
102
What’s the only SSRI effective in people under 18?
Fluoxetine
103
Drug interactions with SSRI
Drugs that increase the risk of bleeding Warfarin Antiepileptic Antipsychotics
104
Duloxetine drug class and when is it indicated?
SNRI Major depression, anxiety, painful diabetic neuropathy, and stress urinalysis incontinence in women
105
Mirtazapine drug class and how it works
Alpha receptor blocker | Increases noradrenaline and serotonin neurotransmission by blocking alpha receptors
106
Common effects of Mirtazapine
Sedation | Weight gain
107
Name the irreversible MAOI
Isocarboxazid Phenelzine Tranylcypromide
108
Examples of SNRI
Duloxetine | Venlafaxine
109
What medication is given for control of deviant antisocial sexual behaviour
First generation antipsychotic- benperidol
110
Which class of antipsychotics are better at treating negative symptoms of schizophrenia
Second generation antipsychotics
111
What’s the MHRA alert for most antipsychotic depot injections
The preparation is used for maintenance treatment and should not be used for the rapid control of acute episodes
112
What is cerebral palsy
Permanent, non-progressive abnormalities of the developing fetal or neonatal brain that lead to movement and posture disorders causing activity limitation and functional impact
113
What is motor neurone disease
A neurodegenerative condition affecting the brain and spinal cord Symptoms include muscle cramps, wasting and stiffness, loss of dexterity, reduced respiratory function and cognitive dysfunction
114
What drug can be used in essential tremor or to control movement disorder
Tetrabenazine
115
What is Parkinson’s disease
A progressive neurogenerative condition resulting from the death of dopaminergic cells of the substantia Nigra in the brain
116
What are the motor symptoms people with Parkinson’s disease present with
Motor symptoms including: hypokinesia, bradykinesia, rigidity, rest tremor and postural instability
117
What are the non motor symptoms people with Parkinson’s present with
Dementia, depression, sleep disturbance, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss
118
What’s the first line drug treatment of motor symptoms in Parkinson’s disease where QOL is affected
Co-careldopa or benserazide
119
What’s the first line drug treatment of motor symptoms in Parkinson’s disease where QOL is not affected
Levodopa (non ergot derived dopamine receptor agonist) or monoamine oxidase B inhibitor (eg: rasagiline and selegiline)
120
What are nonmotor symptoms in Parkinson’s disease
Daytime sleepiness and sudden onset of sleep Postural hypotension Depression Psychotic symptoms Rapid eye movement sleep behaviour disorder Drooling of saliva Parkinson’s disease dementia
121
What is the aim of treatment for Parkinson disease
As the disease is not curable the aim is to improve the quality of life of patients with Parkinson’s
122
When is Parkinson’s drug treatment started
When symptoms reach a level where they are causing a significant impact on daily life
123
Why should Anti-Parkinson drugs be initiated gradually in the elderly
Can cause confusion
124
Give examples of dopamine receptor agonist
Pramipexole Ropinirole Rotigotine Apomorphine
125
What do you levodopa containing drugs interact with
MAOIs
126
How is using MAOBIs with levodopa useful
Reduces the ‘end-of-dose’ deterioration experience
127
How does Entacapone, Opicapone and Tolcapone (COMT inhibitor) work
Prevents the peripheral breakdown of levodopa giving it greater opportunity to reach the brain
128
Common side effect of Entacapone (COMT inhibitors)
Can colour the urine a reddish brown colour
129
What is prolonged levodopa use associated with
Weight loss
130
What can be given to treat nausea and vomiting associated with dopaminergic drugs
Domperidone
131
Why can dopamine agonists be preferred in the long term for younger patients
Associated with fewer dyskinesia and motor fluctuations
132
What negative behavioural symptom are levodopa AND dopamine receptor agonists associated with
Compulsive or disinhibited behaviour | Eg: Gambling, hypersexuality, binge eating
133
How are Antimuscarinic used to help Parkinson’s symptoms
Exerts it’s antiparkinsonism action by Reducing the effects of the relative Central Cholinergic excess that occurs as a result of dopamine deficiency
134
Drug classes involved in Parkinson’s drug treatment
- Antimuscarinic (rarely used) - Catechol-o-methyltranferase inhibitors - Dopamine precursors - Dopamine receptor agonist - Monoamine Oxidase B inhibitor
135
How do you phenothiazines work (eg: prochlorperazine)
They are dopamine antagonist and acts centrally by blocking the chemoreceptor trigger zone Relieves nausea and vomiting caused by migraines
136
What advantage does domperidone have over metoclopramide and other phenothiazine
Less likely to cause central effects such as sedation and dystonic reactions as it doesn’t cross the BBB
137
What is prescribed for meniere disease (ear disease causing a spinning sensation)
Betahistine dihydrochloride
138
What can you buy OTC for occasional insomnia
Promethazine
139
What antiemetic is mostly used in post operative N&V and chemo
Serotonin antagonist (eg: ondansetron)
140
What antiemetic is used for delayed N&V in cisplatin chemo
Aprepitant (neurokinin 1 receptor antagonist)
141
What can you give to treat N&V in Parkinson’s caused by dopaminergic drugs
Domperidone
142
What’s the advantage of metoclopramide over other phenothiazine
It also acts directly on the gastro-intestinal tract so preferred for dmed is associated with gastroduodenal, hepatic and biliary disease
143
Most effective drug for the prevention of motion sickness
Hyoscine hydrobromide (Antimuscarinic)
144
Examples of antihistamines used for nausea and vomiting
Cyclizine | Promethazine (sedating)
145
When are non-opioid drugs (paracetamol and aspirin) and other NSAIDs particularly suitable
Pain in Muscoskeletal conditions
146
When are opioid analgesics suitable
Moderate to severe pain particularly with a visceral origin
147
What effect does paracetamol have
Analgesic | Antipyretic
148
What’s the best analgesia to use in tooth ache
NSAID (ibuprofen, aspirin, diclofenac) Paracetamol
149
Common side effects of opioid use
``` Constipation Respiratory depression Nausea and vomiting Drowsiness Skin rash Dry mouth ``` Dependence
150
What is the most valuable opioid and the standard to which all opioids are compared
Morphine
151
What drug reverses opioids action
Naloxone
152
How is buprenorphine different to other opioids when it comes to naloxone
Naloxone only reverses it’s effects partially
153
Give an example of an opioid with a longer duration of action than morphine
Buprenorphine
154
Which opioid has less of the common opioid adverse effects
Tramadol
155
What’s the most widely used post operative analgesia
Combination of opioid and non-opioid Morphine Paracetamol
156
Possible adverse effects of giving opioids epidurally (unlicensed)
Pruritis Urinary retention Nausea and vomiting Respiratory depression
157
What strengths do co-codamol come in
8/500 15/500 30/500
158
When is codeine contraindicated
Children younger than 12 Fast CYP2D6 ultra-rapid metabolisers Breastfeeding mothers Acute respiratory depression Head injury
159
Signs and symptoms of morphine toxicity
``` Reduced conscienceness Lack of appetite Somnolence -drowsy Constipation Respiratory depression Pin point pupils Nausea and vomiting ```
160
What effect can the variation in codeine metabolism cause
Codeine is metabolised into morphine Ultra rapid codeine metabolisers have a marked increase morphine toxicity Poor codeine metabolisers have a reduced therapeutic effect
161
What do you give in neuropathic pain
``` Amitriptyline Gabapentin Pregabalin Tramadol Corticosteroids ```
162
What do you give for breakthrough pain
Fentanyl or morphine
163
Why should opioids not be used following a head injury
They interfere with neurological assessment
164
Why is dipapanone opioid not suitable for palliative care
It contains cyclizine
165
Name opioid receptor antagonist and how they work
Naloxone and naltrexone Reverse opioid overdose and precipitate withdrawal symptoms
166
What medication can be used for the treatment of acute migraines
Analgesics (paracetamol aspirin) Serotonin receptors agonist (triptans) Ergot alkaloids (Antiemetic if required or a combined analgesic and antiemetic)
167
Why are a ergot alkaloids avoided for migraine
Difficulty in absorption and by its side effects | particularly nausea vomiting abdominal pain and muscular cramps
168
When should preventive treatment for migraine be considered
For patients who suffer at least two attacks a month For patients who suffer an increasing frequency of headaches For patients who suffer significant disability despite suitable treatment for migraine attacks For patients who cannot take suitable treatment for migraine attacks
169
What medication can you use for prophylaxis of migraine
``` Beta-blocker (propranolol being the most common) TCA antidepressant Gabapentin Sodium valproate/ valporic acid Pizotifen ```
170
What’s the Drug treatment of choice for cluster headache
Sumatriptan given intravenously Oxygen for 10-20 minutes can help with an attack
171
When is the prophylaxis of a cluster headache indicated and what is used
It is indicated if the attacks are frequent, if they last over three weeks or if they cannot be treated effectively Verapamil or lithium are used
172
How is Neuropathic pain managed
Tricyclics antidepressants (amitriptyline) or with certain antiepileptic drugs (gabapentin)
173
What can you give a patient with neuropathic pain awaiting review and unable to take oral medication
Typical local anaesthetic preparation such as lidocaine Or Capsaicin
174
Why should you avoid the excessive use of acute treatment for migraine
It’s associated with medication overuse headache
175
Which non-steroidal anti-inflammatory drug is licensed specifically for acute migraine
Tolfenamic acid
176
How long do you have to wait before the dose of a triptan can be repeated
Atleast Two hours
177
Why might it be difficult to withdraw hypnotics and anxiolytics
Dependence and tolerance occur
178
What’s the most commonly used anxiolytic and hypnotic
Benzodiazepines
179
Why are older generation benzodiazepines no used as much as the newer ones
They have more adverse effects and interactions | And are more dangerous in overdose
180
When is benzodiazepine indicated in anxiety or insomnia
When it’s short term and severe
181
What is transient insomnia
Inability to sleep due to other factors like noise shiftwork jetlag etc
182
What is short-term insomnia
Inability to sleep due to emotional problems or illness
183
Which benzodiazepine are used as hypnotics normally
Nitrazepam Temazepam If insomnia is linked with anxiety then diazepam can be used as the hypnotic
184
What are the Z drugs and how do they work
Zaleon, zolpidem and Zopiclone Not benzos but they act on the benzodiazepine receptor
185
What antihistamine can be used for insomnia
Promethazine (not recommended)
186
What age group can melatonin be used in to treat insomnia
Over 55
187
Why are benzodiazepine preferred over barbiturates in insomnia
Less dependence and easier to withdraw
188
What are paracetamol children’s dosing ages 2months - 16 years
(NEED TO ADD- Ronans notes)
189
What’s used as substitution in opioid dependence
Methadone or buprenorphine
190
What happens if a patient misses atleast 3 days of their opioid maintenance therapy
They lose tolerance and are at risk of an overdose
191
Why is methadone the preferred method for opioid dependence over buprenorphine
Although buprenorphine is less sedating (as its only a partial agonist) methadone is preferred as it has milder withdrawal symptoms
192
What do severe cases of alcohol withdrawal include
Seizures Delirium Death
193
What medications are commonly used to control alcohol withdrawal
Chlordiazepoxide (a long acting benzo) Carbamazepine (if benzo not appropriate) Antipsychotic may be added to control delirium
194
What are recovering alcoholics given to prevent relapse
Acamprosate or naltrexone
195
What are alcoholics given to reduce their risks of developing encephalopathy
``` Parental thiamine (pabrinex) Followed by oral thiamine ```
196
What can hepatitis associated with alcohol intake be treated with
Corticosteroids
197
What should be offered to patients trying to quit smoking
Nicotine replacement therapy in many forms | Varenicline- selective nicotine receptor partial agonist
198
What should be monitored with varenicline and when should it be stopped
Psychiatric performance Stop if suicide ideation or depressed moods occur
199
What are common examples of drugs that when a patient stops smoking the dose need to be reduced (as smoking increases the metabolism)
Theophylline Ropinirole Some antipsychotics
200
How long would it take for untreated heroin dependence symptoms to show
8 hours | Can subside after 5 days
201
What is methadone lintus licensed for
As an analgesia in severe pain-and cough in terminal disease
202
Why should Bupropion for smoking cessation not be used in epilepsy
Lowers seizure threshold
203
Why should donepezil be taken in the morning
Vivid dreams have been reported
204
Why do people on clozapine need to take regular blood tests
It causes a severe deficiency in neutrophils (agranulocytosis)
205
When are benzodiazepam commonly indicated
First-line management of seizures and status Epilepticus Personal management of alcohol withdrawal reactions Common choice of sedation for interventional procedures Short-term treatment of severe anxiety or insomnia
206
What are common cholinergic (para sympathomimetics) side effects Clue: D U M B B E L S
``` Diahhroa Urination Muscle weakness, cramps Bronchospasm Bradycardia Emesis (vomiting) Lactimation (teary eyes) Salivation/ sweating ```
207
What is the MHRA alert regarding antiepileptic drug switching List the 3 catergories and the drugs in them
Potential harm when switching between different manufacturer products for a particular drug Catergory 1: maintain the same product (CP3) Carbamazepine, phenytoin, phenobarbital, primidone Catergory 2: clinical judgment Valproate, lamotrigine, clonazepam, topiramate Catergory 3: don’t need to maintain the same product
208
What’s the caution of taking carbamazepine with contraception?
It reduces the efficacy of hormonal contraception
209
Which anti epileptic drugs are present in high amounts in milk (clue: Z E L P)
Zosinanide Ethosuximide Lamotrigine Primidone
210
What’s the MHRA alert regarding Gabapentin
Risk of severe respiratory depression
211
How does phenytoin work
It binds to neuronal sodium channels in their inactive state to prolong activity
212
Signs and symptoms of phenytoin drug toxicity (clue: S N A C H D)
``` Slurred speech Nystagmus (uncalled eye movement) Ataxia (uncontrolled muscle movement) Confusion Hyperglycaemia Diplopia (double vision, blurred vision) ```
213
How does carbamazepine work
It inhibits neuronal sodium channels, stabilises membrane potential and reduced neuronal exciteability
214
Signs and symptoms of carbamazepine toxicity (clue: I handbag)
``` Inco-ordination Hyponatraemia Ataxia (involuntarily muscle movement) Nystamus (involuntary eye movement) Drowsiness Blurred vision Arrhythmia GI disturbances ```
215
What’s status epilepticus and what’s the treatment
Epileptic fits follow one after the other without regaining consciousness (>5 minutes) IV lorazepam (not diazepam as can cause thrombophlebitis)
216
How does methylphenidate and Dexamfetamine work, it’s drug schedule and what’s it used for
It’s a potent CNS stimulant it increases dopamine and noradrenaline levels in the brain Schedule 2 CD Used as first like in ADHD
217
What’s used in acute episodes of mania and hypo mania
Benzodiazepines Antipsychotics (QOR)- quetiapine, olanzapine, risperidone (Lithium or valporic acid added if antipsychotic alone is not adequate)
218
What’s used in the prophylaxis of bipolar disorder
Lithium salts Valproate Olanzapine
219
What’s the therapeutic range for lithium
0.4mmol- 1mmol/L
220
Signs and symptoms or lithium toxicity (clue: R E V N G)
``` Renal disturbances (excessive urination) Extrapyrimidal symptoms Visual disturbances Nervous system disturbances Gastro intestinal disturbances (vomiting and diarrhoea) ```
221
Side effects of lithium
``` Thyroid disorders Renal impairment Hypertension QT prolongation Lowers seizure threshold ```
222
What’s the only antidepressant safe to use on children
Fluoxetine
223
What antidepressant prolong QT INTERVAL
Citalopram and Escitalopram
224
What’s less sedating, less Antimuscarinic and less cardio toxic, TCA or SSRI
SSRI
225
Why does metoclopramide have a maximum 5 day use?
MHRA ALERT It has a risk of neurological adverse effects (EPSE due to crossing the BBB)
226
Why does domperidone have a maximum use of 1 week?
MHRA ALERT | Risk of cardiac side effects
227
Opioid side effects (clue morphine)
``` Miosis (pin point pupils) Out of it (sedation) Respiratory depression Postural hypotension Hallucinations Infrequency (urinary, constipation) Nausea and vomiting Euphoria ```
228
Why should codeine and dihydrocodeine never be given via the IV route?
Severe reaction similar to anaphylaxis | CD2 when given the IM route
229
Why’s codeine not given to children under 12
Can cause breathing problems | The metabolism into morphine is unknown
230
What drugs lower seizure threshold
Tramadol TCA SSRI
231
What’s used for anxiety
Benzodiazepines Barbiturates Buspirone
232
Of the meds used for anxiety, which ones not a sedative
Buspirone
233
What do you monitor with phenobarbital
CLUE: LOW AND SLOW Low respiratory Low blood pressure Sedation
234
In terms of the patients bloods, when is giving lithium contraindicated
Hyponatraemia | Dehydration
235
What needs to be counselled for a patient starting carbemazipine and on oral contraception?
Oral contraceptives not effective will need alternative birth control method
236
What’s an important possible adverse effect of donepezil
Neuroleptic malignant syndrome
237
Which side effect should galantamine be stopped immediately
First appearance of a skin rash | Risk of SJS
238
What is important to note with contraception and antiepileptic
Enzyme inducing antiepileptics (eg: carbamazepine) reduce the efficiency of hormonal contraception
239
Which antiepileptic are present in high amounts in breast feeding milk (clue ZELP)
Zosinamide Ethosuximide Lamotrigine Primidone
240
What would you give for a convulsive status epilepticus?
IV lorazepam | Avoid IV diazepam as it causes thrombophlebitis
241
What’s the MHRA alert for the nsaid piroxicam
Should not exceed 20mg OD
242
Which NSAID is best to give to a patient with high CV risk
Ibuprofen <1.2g daily Naproxen <1g
243
Which drugs can cause Parkinsonism symptoms
``` Cinnarizine Flunarozine Pet hiding Sodium valproate Amiodarone Metoclopramide ```
244
Why should Z drugs and benzodiazepines be avoided in elderly
Ataxia and confusion = falls/ injury
245
What vitamin deficiency can excess alcohol cause
Vitamin B1 (thiamine)
246
What needs to be monitored with methylphenidate for ADHD and why
Weight and height As it can affect the growth of some children
247
Which antidepressant drug can increase the risk of bleeding
Sertraline
248
How many weeks can it take for buspirone to work
Up to 2 weeks
249
What’s the wash out period for the different anti depressants
MOAI wait 2 weeks SSRI wait 1 week TCA wait 1-2 weeks (3 weeks if imipramine or clomipramine)
250
How long does it take for buspirone to work
2 weeks
251
Common adverse effect of pizotifen (used for headaches)
Weight gain
252
Which antiepileptic carried an increased risk of cleft palates if taken in the first trimester or pregnant
Topiramate
253
Lithium and ACEi interaction
ACEi increased the concentration of lithium
254
What needs to be monitored and how often with lithium
BMI Serum electrolytes Renal function Thyroid function Every 6 months
255
What do you give for Alzheimer’s disease for a patient with Parkinson’s disease
Rivastagmine
256
What’s given for non cognitive symptoms of dementia including extreme violence, aggression and extreme behaviour
Oral benzodiazepines Or Antipsychotics (If IM needed lorazepam, halopiredol, olanzapine)
257
Most antiepileptics are BD dosing, name the OD ones
Lamotrigine Perampanel Phenytoin
258
Which antiepileptic require you to monitor foetal growth
Topiramate | Levetiracetam
259
What’s advices for women to take when they become pregnant and on anti epileptics
5mg folic acid until 12 weeks
260
Which antiepileptic can inhibit sucking reflex in babies
Phenobarbitals and primidone
261
What’s febrile convulsions and what’s used for it
Seizures that occur when a child has a high fever Paracetamol (antipyretic) If >5 minutes treat as a status epilepticus (IV lorazepam)
262
Psychological symptoms of anxiety
``` Restlessness Worry Fear Difficulty swallowing Irritability ```
263
Physical symptoms of anxiety
``` Palpitations Muscle aches and tension Trembling and shaking Excessive sweating SOB Insomnia ```
264
Whens lithium blood samples taken
12 hours after dose
265
Counselling for diet on lithium
Don’t have significant changes to your diet especially sodium
266
Which antidepressants have a higher risk of withdrawal reactions
Paroxetine | Venlafaxine
267
MHRA alert for clozapine
GI obstruction
268
What’s used in advanced Parkinson disease
Apomorphine
269
What strength of morphine oral solution counts as a CD5
13mg/5ml or less
270
The first line parenteral route for opioids
Diamorphine (heroin)
271
What’s the equivalent diamorphine dose to morphine
1/3 of the morphine dose
272
What should you counsel with patch medications
Avoid exposure to external heat (eg: sauna) as it results in increased absorption And rotate patch site
273
What’s the MHRA advice for codeine use in 12-18 year olds
Max 240mg a day for 3 days
274
Which opioid also affect the noradrenaline and serotonin uptake
Tramadol
275
What interactions does tramadol have
It lowers seizure threshold Bleeding risk (warfarin) Serotonin syndrome
276
What can you use for conscious sedation of dental procedures
Temazepam
277
Which SSRI has a long half life
Fluoxetine
278
Epilepsy treatment options in kids
Sodium valproate Leveretacium Topiramate
279
Is routine plasma concentration required for lithium and sodium valproate
No
280
Interactions with lithium
ACEi - lithium toxicity NSAIDs- lithium toxicity Diuretics- hyponatraemia Amiodarone- risk of arrhythmia
281
What should be counselled when giving disulfiram (treatment of alcohol dependence)
Alcohol should be avoided atleast 1 week after therapy has stopped Patients should not ingest alcohol at all as there a serious interaction
282
Can you breast feed while on anti epileptics drugs
Yes safe with nearly all of them
283
Is opioid analgesic safe to use in pregnancy
Contraindicated in the 3rd trimester as it can depress neonatal respiration
284
How can you treat neuroleptic malignant syndrome
Dopamine receptor agonist Bromocriptine or Dantrolene
285
Why would you caution metoclopramide in female adolescents
Extrapyramidal side effect
286
What’s preferred for motion sickness when the journeys long
Old generation antihistamines as they have a long mode of action
287
Why should patients be adviced to take migraine meds straight away on an onset of an attack
When migraine occurs gastric emptying slows down so absorption is reduced
288
When do you refer for a migraine?
Symptoms occurring for the first time Migraine in a child Medication not relieving symptoms First migraine occurred after the age of 40
289
What medications are sold otc for insomnia
Diphenhydramine (treatment of choice) and promethazine
290
What is epilepsy
A disorder of the brain characterised by: Atleast 2 unprovoked seizures occurring more that 24 hours apart One unprovoked seizure and a probability of further seizures
291
Which dementia is drug treatment not recommended for
Vascular dementia And with the others should only be continued if there’s behavioural or cognitive benefit
292
What can be given to minimise neonatal haemorrhage in newborns where the mother was taking anti epileptic medication
Vitamin K injection
293
Which medication can cause the most withdrawal effects from the mother taking them in newborns
Benzodiazepine | Phenobarbital
294
What should all breastfed infants where the mothers taking antiepileptic medications be monitored for
``` Drowsiness Weight gain Feeding difficulty Adverse effects Developmental milestones ```
295
What has MHRA reported with all antiepileptic drugs
Increased with of suicidal behaviour and thoughts and
296
Which antiepileptic medication cause blood dyscrasias and should report signs of infections
‘C vet pls’ ``` Carbamazepine Valproate Ethosuximide Topiramate Phenytoin Lamotrigine Zonisamide ```
297
What antiepileptic medication can cause eye problems
Vigabatrin (visual symptoms) | Topiramate (raised intra ocular pressure)
298
Name a few CNS depressants
``` Benzodiazepines Opioids Hypnotics Barbiturates Antipsychotics Lithium Antidepressants Alcohol Antiepileptic ```
299
Side effects of phenytoin
``` Change in appearance (rash) Blood dycrasias Hypersensitivity reaction Rashes (chinese and Thai patients with HLAV*1502 allele are at risk of Sjs) Low vitamin d- osteomalacia and rickets Hepatotoxicity Suicidal ideation ``` Iv route- bradycardia and hypotension
300
Side effects of carbamazepine
``` Blood dyscrasias Hepatotoxicity Hypersensitivity reaction Rashes (chinese and Thai patients with HLAV*1502 allele are at risk of Sjs) Hyponatraemia ```
301
What’s the conditions of PPP for valproate supply
7 day prescription 30 day supply Use highly effective contraception Exclude pregnancy before treatment Fully informed of the risk of use in pregnancy and sign a form
302
What do the nations of the pharmacist include everytime they dispense valproate
Remind of risk of pregnancy and need for contraception Remind of need for annual specialist review Dispense as whole patch when possible Provide valproate patient card Provide patient guide Refer patient to GP if not taking contraception
303
Side effects of valproate
Hepatotoxicity (fatal) Blood dysrasias Pancreatitis Monitor: liver function test and full blood count
304
How would you withdraw diazepam
Gradually convert to equivalent diazepam dose ON over 1 week Reduce diazepam dose by 1-2mg increments every 2-4 weeks Reduce diazepam dose further- can reduce in smaller steps of 500mcg towards the end
305
What should the withdrawal period be for antipsychotics
4 weeks of still being treated with other anti manic meds 3 months of completely stopping
306
How long should prophylactic treatment of bipolar disorder be continued
2 years from last manic episode 5 years if experienced a relapse
307
What concentration are you likely to experience toxic effects with lithium
2mmol/ L
308
Which antidepressant doesn’t require a washout period
Moclobemide Due to the short acting/ reversible action
309
What’s the washout period for fluoxetine
5 weeks
310
What determines the choice of antipsychotic
Group 1 more sedative and more EPSE so if has Parkinson’s and if not wanted group 2 chosen Group 2 more metabolic side effects so if overweight or has diabetes group 1 chosen Level of sedation required also determines choice
311
How long should you give to assess clozapine response
8-10 weeks
312
How many missed doses of clozapine till it needs to be referred to specialist
2 or more missed doses
313
Side effect of the antipsychotic pimozide
Qt prolongation, cases of sudden death
314
What does selegiline metabolise to
Amphetamine
315
What should be added to parkinsons id dyskinesia is not adequately managed by modifying therapy
Amantadine
316
What’s reserved advanced Parkinson’s disease and what’s the use
Apormorphine Used in motor fluctuations in the off period
317
What’s the use of carbidopa and beserazide
To get more levodopa into the brain with a smaller dose Transporter
318
Whys it important to take levodopa at a specific time each day
To avoid off periods
319
Why are Ergot derived medication not used in Parkinson disease
Side effect of fibrotic reactions
320
Why’s entacapone preferred over tolcapone
Tolcapone can cause loose threatening hepatotoxicity
321
What’s break through pain?
Sudden flare of Pain that breaks through regular medication
322
What’s the doses of rescue dose
Min 1/10th Max 1/6th Of the total dose of strong opioid every 2-4 hours PRN
323
Cautionary and advisory labels on opioids
Warning. This medication may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol
324
What increments can morphine be increased
1/3 or 1/2 total daily dose per 24hours
325
What parental dose is equivalent to an oral dose
Parental dose is equivalent to half the oral dose
326
What’s the equivalent dose of diamorphine to oral morphine
Diamoprhine is equivalent to 1/3 of oral morphine
327
How long can buprenorphine patches last Fentanyl?
3, 4 or 7 days Fentanyl- 3 days
328
What can be used to treat daytime symptoms in Parkinson’s patients
Modafinil
329
Why does carbamazepine have a higher maintenance dose than losing dose
It is an enzyme auto inducer | So it induces its own metabolism so maintenance dose is higher than the initial dose
330
What’s the interaction between sumatriptan and tramadol
Both increase the risk of serotonin syndrome
331
Which antiemetics are less teratogenic
Lamotrigine and levetiracetam

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