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CNS Flashcards

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1
Q

epilepsy withdrawing drugs?

A

one at at time!

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2
Q

LITHIUM MONITORING?

65+?

A

LITHIUM MONITORING? weekly till stable, every 3 months first year, every 6 months thereafter

65+? every 3 months (poor control, poor renal, etc)

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3
Q

EPILEPSY ATTACK, alcohol ting

A

Immediate measures to manage status epilepticus include positioning the patient to avoid injury, supporting respiration including the provision of oxygen, maintaining blood pressure, and the correction of any hypoglycaemia. Parenteral thiamine should be considered if alcohol abuse is suspected; pyridoxine hydrochloride should be given if the status epilepticus is caused by pyridoxine hydrochloride deficiency.

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4
Q

EPILEPSY INFANTS SECTION?

A
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5
Q

NEUROPATHIC PAIN

TOPICAL LOCALISED?

A

LIDOCAINE/

CAPSAICIN (intense burning sensation may limit use)

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6
Q

NEUROPATHIC PAIN

OPIATES?

A

MORPHINE/OXYCODONE/TRAMADOL
that order

tramadol not rated

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7
Q

NEUROPATHIC PAIN

ANTIEPILEPTICS?

A

GABAPENTIN/PREGABALIN (1 week withdrawal regimen)

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8
Q

NEUROPATHIC PAIN

TCAs?

A

AMITRIPTYLINE/NORTRIPTYLINE

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9
Q

FENTANYL PATCHES?

A

REMOVE PATCH IMMEDIATELY IF THERE ARE SIGNS OF TOXICITY

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10
Q

PATCHES ADVICE?

A

AVOID EXPOSURE TO HEAT
APPLY TO DRY HAIRLESS AREA
ROTATE SITE

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11
Q

OXYCODONE MORE POTENT THAN MORPHINE?

A

More appropriate, less nausea

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12
Q

SWTICHING BETWEEN OPIATES TO PREVENT OD?

A

REDUCE DOSE BY 1/2 TO 1/3

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13
Q

Patient on 120mg morphine, dose increase?

A

Max. increase by 1/3 to 1/2 each day, i.e.
40-60mg increase

???

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14
Q

STRONG OPIATES

BREAKTHROUGH PAIN?

A

1/6th- 1/10th of total daily dose, /2-4hours

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15
Q

STRONG OPIATES

AVOID IN…?

A

PARALYTIC ILEUS
RESPIRATORY DISEASE HEAD INJURY

?????

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16
Q

STRONG OPIATES

OVERDOSE?

A

GIVE NALOXONE

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17
Q

STRONG OPIATES

PROLONGED USE SIDE-EFFECTS?

A

HYPOGANADISM- less hormone secretion
ADRENAL INSUFFICIENCY- heightened sensitivity to pain
HYPERALGESIA

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18
Q

OPIATES SIDE-EFFECTS?

A 
Act on mu-pathway causing:
DRY MOUTH
CONSTIPATION
CNS DEPRESSION
N&V
HYPOTENSION
MIOSIS (pupil constriction)
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19
Q

CODEINE

AGE?

AVOID IN x3?

A

AGE? 12+ (Linctus- 18+?)

AVOID IN x3?
U18 children who had tonsils remove due to sleep apnoea
(Afro-Caribbean) patients who are ultra-rapid metaboliser due to toxicity?
Breastfeeding

Children under 12, respiratory side-effects!

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20
Q

PAIN MANAGEMENT

MODERATE-SEVERE?

A

ALL THE CDs!

STRONG OPIATES: MORPHINE/OXYCODONE/METHADONE/BUPRENORPHINE/FENTANYL

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21
Q

PAIN MANAGEMENT

MILD-MODERATE?

A

WEAK OPIATES: CODEINE/DIHYDROCODEINE

MODERATE: TRAMDOL (but lowers seizure threshold, serotonin syndrome, risk of bleed, psychiatric disorder

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22
Q

PAIN MANAGEMENT

MILD?

A

NON-OPIATES: PARACETAMOL/NSAIDs/ASPIRIN

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23
Q

METOCLOPRAMIDE

SIDE-EFFECTS?

DOSE?

MINIMUM AGE?

MAX. DAYS?

A

SIDE-EFFECTS? EPse, crosses BBB

DOSE? 10mg TDS (samesame)

MINIMUM AGE? 18 years old

MAX. DAYS? 5

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24
Q

DOMPERIDONE

DOES NOT CROSS?

DOSE?

MINIMUM AGE?

MAX. DAYS?

MINIMUM WEIGHT?

SIDE-EFFECT?

A

DOES NOT CROSS? The BBB, so used in PD, SO WHAT

DOSE? 10mg TDS

MINIMUM AGE? 12 years old

MAX. DAYS? 7

MINIMUM WEIGHT? 35kg+

SIDE-EFFECT? QT prolongation

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25
PARKINSON'S N&V?
DOMPERIDONE Haloperidol/Levmepromazine-> antipsychotics, reduce dopamine levels, L HYPOTENSION RISK!
26
PREVENTION & TREATMENT OF POSTOPERATIVE N&V CAUSED BY OPIOIDS/GENERAL ANAESTHETICS?
CYCLIZINE
27
PALLIATIVE CARE N&V?
HALOPERIDOL/LEVOMEPROMAZINE
28
MOTION SICKNESS?
hysocine HYDRObromide hyoscine BUTYLbromide (GI system)
29
PREOPERATIVE ANTICIPATORY?
LORAZEPAM (short-acting)
30
POSTOPERATIVE N&V?
POSTOPERATIVE N&V? | 5HT-3 receptor antaognist (Ondansetron)/Dexamethasone
31
PROPHYLAXIS/TREATMENT OF N&V PREGNANCY? SEVERE VOMITING?
PREGNANCY? Nausea in first trimester- generally mild/does not require drug therapy SEVERE VOMITING? Short-term treatment-> anithistamine, e.g. promethazine/prochlorperazine/metoclopramide
32
PROPHYLAXIS/TREATMENT OF N&V?
PROPHYLAXIS/TREATMENT OF N&V? Antihistamines- Cyclizine/Promethazine Phenothiazines- Prochlorperazine
33
TENSION HEADACHE SYMPTOM? TREATMENT?
SYMPTOM? Bilateral throbbing pain-> tight band around your head TREATMENT? Paracetamol/Ibuprofen
34
TRIGEMINAL NEURALGIA SYMPTOM? TREATMENT?
SYMPTOM? Severe facial pain, electric shock-like in jaw/teeth/gums TREATMENT? Carbamazepine
35
CLUSTER HEADACHES TREATMENT ACUTE? PROPHYLAXIS? VLP-E
``` ACUTE? SC sumatriptan (give nasal sumatriptan/zolmitriptan if unavailable) ``` PROPHYLAXIS? Verapamil/Lithium/Prednisolone/Ergotamine tartate (rare)
36
HEADACHES CLUSTER SYMPTOM?
INTENSE UNILATERAL PAIN IN/AROUND ONE EYE
37
TRIPTANS CONTRAINDICATED IN..?
``` IHD HYPERTENSIONS PVD MI TIA ANYTHING HEART! (as it narrows blood vessels) ```
38
MIGRAINE PROPHYLAXIS TOPIRAMATE?
Caution in women of child-bearing potential Advice on risks during pregnancy Teratogenic- cleft palate in first trimester
39
MIGRAINE PROPHYLAXIS EPISODIC/CHRONIC Unlicensed Treatment? Limited Evidence?
EPISODIC/CHRONIC? UNLICENSED- SODIUM VALPROATE/FLUNARIZINE Limited evidence- PIZOTIFEN
40
MIGRAINE PROPHYLAXIS AMITRIPTYLINE is effective BUT if not tolerated..?
AMITRIPTYLINE is effective BUT if not tolerated..? | Use less sedating TCA
41
MIGRAINE PROPHYLAXIS 1st LINE? 2nd LINE?
1st LINE? PROPRANOLOL 2nd LINE? METOPROLOL/NADOLOL VALPROATE/PIZOTIFEN/BOTOX ALSO USED...
42
ACUTE MIGRAINE ANTIEMETICS?
Metoclopramide/Prochlorperazine (unlicensed) can be given as single dose at onset of migraine symptoms Don't use Metocopramide regularly- EPse (5 days) Domperidone- unlicensed in <35kg (7 days)
43
ACUTE MIGRAINE Unable to take first-line options?
Give souble paracetamol
44
ACUTE MIGRAINE W/ AURA? REPEAT?
W/ AURA? Take triptan at the START of headache and NOT at the start of aura REPEAT? Repeat Triptans after 2 hours (Naratriptan 4 hours) ONLY if there has been a response to 1st dose (but inadequate)
45
MIGRAINE ACUTE TREATMENT 1ST LINE?
ACUTE TREATMENT? Aspirin/Ibuprofen/5HT-1 receptor agonist (Sumatriptan favoured) take as soon as patient knows they've got a migraine
46
MIGRAINE LIFESTYLE ADVICE?
``` LIFESTYLE ADVICE? Maintain hydration/sleep/exercise Avoid chocolate+wine Relax after stress Headache diary- identify triggers ```
47
MIGRAINE W/ AURA SYMPTOMS?
W/ AURA SYMPTOMS? Visual (zigzag/flickering lights, spots, lines) Sensory (pins & needles, numbness) Dysphasia
48
MIGRRAINES SYMPTOMS?
Unilateral/pulsating | N&V, photophobia & phonophobia
49
OPIOID DEPENDENCE METHADONE?
METHADONE? Causes QT prolongation Carefully titrate according to patient's needs
50
OPIOID DEPENDENCE x4 BUPRENORPHINE KEY POINTS?
``` x4 BUPRENORPHINE KEY POINTS? Less sedating than methadone Milder withdrawal symptoms Lower risk of OD Suboxone (buprenorphine w/ naloxone) given when there is risk of injecting ```
51
OPIOID DEPENDENCE? High risk of overdose?
High risk of overdose? Naloxone
52
OPIOID DEPENDENCE PREGNANCY?
PREGNANCY? Continue treatment
53
OPIOID DEPENDENCE MISSED 3 DAYS OR MORE?
MISSED 3 DAYS OR MORE? Risk of OD, loss of tolernace, consider reducing dose, refer to specialist
54
OPIOID DEPENDENCE Prescribed on form?
Prescribed on form? FP10MDA-> max. supply of 14 days
55
NICOTINE DEPENDENCE NICOTINE-REPLACEMENT THERAPY (NRT)?
NICOTINE-REPLACEMENT THERAPY (NRT)? Use a patch (16-hr if pregnant/nightmares) AND Use a short-term reliever: lozenges/gum/sublingual tablets/inhalator/nasal/oral spray
56
NICOTINE DEPENDENCE BUPROPION?
BUPROPION? | Avoid in psychiatric illness/seizures/eating disorders
57
NICOTINE DEPENDENCE VARENICLINE?
VARENICLINE? | Avoid in epilepsy/cardiovascular disease/psychiatric illness
58
ALCOHOL DEPENDENCE WERNICKE'S ENCEPHALOPATHY TREATMENT?
WERNICKE'S ENCEPHALOPATHY TREATMENT? Thiamine (Vitamin B1)
59
ALCOHOL DEPENDENCE DELIRIUM TREATMENT?
DELIRIUM TREATMENT? Lorazepam
60
ALCOHOL DEPENDENCE WITHDRAWAL SYMPTOMS TREATMENT?
WITHDRAWAL SYMPTOMS TREATMENT? | L-A benzodiazepine, e.g. Chlordiazepoxide/Diazepam (alternative: carbamazepine/clomethiazole)
61
ALCOHOL DEPENDENCE TREAT WITH?
TREAT WITH? CBT->Acamprosate/Naltrexone (alternative: disulfram)
62
SUBSTANCE DEPENDENCE ALCOHOL DEPENDENCE MILD? MODERATE? SEVERE?
MILD? Do not need assisted alcohol withdrawal MODERATE? Treated in a community setting, unless high risk of developing alcohol withdrawal seizures/delirium SEVERE? Undergo withdrawal in an inpatient setting
63
LISDEXAMFETAMINE & DEXAMFETAMINE OVERDOSE signs? TREATMENT?
OVERDOSE? Amfetamines cause: wakefulnness/excessive activity/paranoia/hallucinations/hypertension Followed by: exhaustion/convulsions/hyperthermia/coma TREATMENT? diazepam/lorazepam
64
LISDEXAMFETAMINE & DEXAMFETAMINE SIDE-EFFECTS & MONITORING? Similar to METHYLPHENIDATE
65
METHYLPHENIDATE SIDE-EFFECTS? MONITOR? BPPAWH
``` SIDE-EFFECTS? CNS stimulant Hypertension/Tachycardia/Arrythmias Mood change/Drowsiness/Sleep disorders Decreased appetite/Weight loss Growth retardation (children) ``` ``` MONITOR? At initiation/after dose adjustments/6 monthly Pulse BP Psychiatric symptoms Appetite Weight Height ```
66
ADHD MR-prep preferred?
``` MR-prep preferred? Because of their.. pharmacokinetic profile convenience improved adherence ``` PRESCRIBE AS BRAND ONLY
67
ADHD- ADULT TREATMENT 1st LINE? 2nd LINE?
1st LINE? Use methylphenidate/lisdexamfetamine (dexamfetamine if patient can't tolerate long duration of action) 2nd LINE? Atomoxetine (causes QT prolongation, hepatotoxicity & suicidal ideation
68
ADHD Children intolerant of both methylphenidate & lisdexamfetamine?
Children intolerant of both methylphenidate & lisdexamfetamine? Atomoxetine Guanfacine (unlicensed)
69
ADHD >/= 5years?
>/= 5years? 1) Methylphenidate, first-line 2) If 6 week trial of methylphenidate at max. tolerated dose NOT reduce symptoms? switch to Lisdexamfetamine (Dexamfetamine, unlicensed, used if patients cannot tolerate longer duration of action of Lisdexamfetamine)
70
Z-HYPNOTICS Benzodiazepines+Z-drugs? SIDE-EFFECTS? PD^2
Benzodiazepines (clonazepam/lorazepam)+Z-drugs? Avoid in elderly due to risks of fall and injury SIDE-EFFECTS? PD^2 Paradoxical side-effects Drowsiness Dependance
71
Z-HYPNOTICS ``` Examples? Increases GABA? Dependency? When to take it? Max. duration? ```
Examples? Zolpidem/Zopiclone Increases GABA? ->CNS depression Dependency? Occurs within 3-14 days of use When to take it? Taken intermittently Max. duration? Use for 4 weeks max.
72
BENZODIAZEPINES SHORT-ACTING BENZODIAZEPINES? LLT
SHORT-ACTING BENZODIAZEPINES? Loporazolam/Lormetazepam/Temazepam Little/no hangover effects Used for sleep onset Higher chance of withdrawal symptoms
73
BENZODIAZEPINES LONG-ACTING BENZODIAZEPINE? NDF sleep
LONG-ACTING BENZODIAZEPINE? Nitrazepam/Diazepam/Fluarazepam Higher hangover effect following day Used for sleep maintenance
74
BENZODIAZEPINES LONG-ACTING BENZODIAZEPINE? ADC^2
ALPRAZOLAM DIAZEPAM CHLORDIAZEPOXIDE HYDROCHLORIDE CLOBAZAM Can induce hepatic coma, especially long-acting benzodiazepines
75
SLEEP DISORDERS CHRONIC INSOMINA?
CHRONIC INSOMNIA? cause: anxiety/depression/alcohol/drug abuse Treat underlying psychiatric complaint
76
SLEEP DISORDERS SHORT-TERM INSOMNIA?
SHORT-TERM INSOMNIA? emotional problem/serious medical illness Hypnotic is useful, don't give more than 3 weeks (1 week ideal)
77
SLEEP DISORDERS TRANSIENT INSOMNIA?
TRANSIENT INSOMNIA? external factors- noise, shift work & jet lag Give rapidly eliminated hypnotic- only 1/2 doses
78
SLEEP DISORDERS TRANSIENT INSOMNIA?
TRANSIENT INSOMNIA? external factors- noise, shift work & jet lag Give rapidly eliminated hypnotic- only 1/2 doses
79
MAO-I Washout Periods Don't start MAOI until...
Don't start MAOI until... - 2 weeks after a previous MAOI has been stopped (0 weeks for moclobemide) - 1-2 weeks after a TCA (3 weeks for clomipramien/imipramine) - 1 week after an SSRI (5 weeks for fluoxetine)
80
MAO-I Washout Periods Other antidepressants should not be started...
Other antidepressants should not be started... | For 2 weeks after treatment with MAOIs (3 weeks if clomipramine/imipramine)
81
x5 MAO-INHIBITORS KEY POINTS?
Specialist use Causes hepatoxicity (phenelzine+isocarboxazid) Hypertensive crisis- DO NOT GIVE OTC pseudoephedrine AVOID tyramine-rich foods Tranylcypromine+Clomipramine= FATAL
82
TRICYCLIC ANTIDEPRESSANTS- INTERACTIONS?
INTERACTIONS? CYP inhibitors (grapefruit, increases conc) CYP inducer (reduces effectiveness) QT prolongation (amiodarone, sotalol, quinolone) Anti-muscarinic drugs (oxybutynin, solifenacin, tamsulosin) Anti-hypertensive drugs Hyponatraemia
83
TRICYCLIC ANTIDEPRESSANTS SIDE-EFFECTS? CASHH
``` SIDE-EFFECTS? CASHH Cardiac events Anti-muscarinic Seizures Hypotension Hallucinations ``` DANGEROUS IN OVERDOSE
84
TRICYCLIC ANTIDEPRESSANTS DANGEROUS OD?
DANGEROUS OD? | Amitriptyline/Dosulepin- dangerous in overdose, not recommended for depression, specialist-led!
85
TRICYCLIC ANTIDEPRESSANTS LESS SEDATING? NIL
LESS SEDATING? better for withdrawn/apathetic patients Nortriptyline Imipramine Lofepramine
86
TRICYCLIC ANTI-DEPRESSANTS ``` SEDATING? Better for who? A C D T ```
``` SEDATING? better for agitated/anxious patients Amitriptyline Clomipramine Dosulepin Trazodone ```
87
WHAT IS SEROTONIN SYNDROME? CAN CAUSED BY?
CAN Cognitive: headache, agitation, hypomania, confusion Autonomic: sweating, hyperthermia, nausea, diarrhoea Neuromuscular Excitation: myoclonus, tremor, teeth grinding ``` CAUSED BY? SSRIs, TCAS, MAO-Is Triptans Tramadol Lithium ```
88
SSRIs- INTERACTIONS? | C^2QBHS
CYP inhibitors (grapefruit, increases plasma conc.) CYP inducers (St John's wart, phenobarbital, phenytoin, less effective) QT prolongation (amiodarone, sotalol, quinolone- cipro, levo, macrolides) Bleed Hyponatraemia (carbamazepine, diuretics) Serotonin Syndrome
89
SSRIs- SIDE EFFECTS? GASHBIQ
``` GASHRIQ GI Disturbances Appetitite/Weight Gain Sexual Dysfunction Hyponatraemia Bleed (avoid NSAIDs, warfarin, PPI key) Insomnia (take OM) QT Prolongation (Escitalopram/Citalopram) ```
90
SSRIs- x3 KEY POINTS?
Better tolerated Safer in OD Safest in patients w/ cardiac events SERTRALINE= SAFE, CVD
91
Depression 5-17 years, SSRI?
Fluoxetine
92
DEPRESSION- TREATMENT? 1st line? DOES NOT WORK?
1st line? SSRI (fluoxetine, sertraline, citalopram) ``` DOES NOT WORK? Increase dose Change SSRI Mirtazapine MAO-I (specialist) TCA/Venlafaxine (severe) ``` Still doesn't work? Add in lithium OR antipsychotics Use electroconvulsive therapy in severe refractory depression
93
DEPRESSION MILD? MODERATE-SEVERE?
MILD? CBT MODERATE-SEVERE? Antidein fpressants Patient may feel worse in first 1-2 weeks Take for 4 weeks (6 in elderly) before deemed ineffective Take for... 6 months after remission 1 year in elderly 2 years in recurrent
94
DEPRESSION is?
A reduction of serotonin/dopamine/norephedrine at the synaptic cleft
95
BENZODIAZEPINES- WITHDRAWAL Withdrawal symptoms? 3 STEPS?
Withdrawal symptoms? anxiety/sweating/weight loss/tremors/loss of appetite 3 STEPS? 1) Convert all meds to diazepam x1 ON 2) Reduce by 1-2mg (1/10th on larger doses) /2-4 weeks only further withdraw if patient has overcome withdrawal symptoms 3) Reduce further (0.5mg near the end)
96
BENZODIAZEPINE SIDE-EFFECTS? COLD FT LEGAL LIMIT? OD TREATMENT?
- PARODOXICAL- aggression, hostility, talkative - SEDATION- increased w/ alcohol use/CNS depressant/CYP inhibitors ``` -AVOID driving if drowsy- legal limit (COLD FT) Clonazepam Oxazepam Lorazepam Diazepam Flunitrazepam Temazepam ``` OD TREATMENT? Flumazenil- can prevent need for ventilation (avoid in OD TCA mixed) Activated charcoal can be given within 1 hour of ingesting a significant quantity of benzodiazepine- if patient awake+protected airway
97
BENZODIAZEPINES- CAN INDUCE? LONG-ACTING? SHORT-ACTING?
CAN INDUCE? Hepatic coma, especially long-acting LONG-ACTING? DC^2 Diazepam Chlordiazepoxide Clobazam SHORT-ACTING? Lorazepam (epilepsy) quick to act Oxazepam S-A preferred in hepatic impairment/elderly BUT... S-A greater risk of withdrawal symptoms (max. 2-4 weeks use)
98
ANXIETY- TREATMENT ACUTE? CHRONIC?
ACUTE? Lorazepam/Diazepam- short term use, lowest dose CHRONIC? SSRIs- sertraline, citalopram, fluoxetine Propranolol- alleviates physical symptoms only
99
CLOZAPINE- SIDE-EFFECTS?
MAG Myocarditis+Cardiomyopathy- report+stop on tachycardia Agranulocytosis+Neutropenia- monitor leucoyes+diff. BC (report infection symptoms) GI Disturbances: report+stop on constipation->intestinal block
100
CLOZAPINE- HIGH-RISK DRUG USED IN? WHEN? MISSED MORE THAN 2 DOSES? MONITOR X? WHEN?
USED IN? WHEN? Resistant schizophrenia when... 2+ antipsychotics including a 2nd gen has been used for 6-8weeks each MISSED MORE THAN 2 DOSES? Specialist reinitiation MONITOR X? WHEN? Leucocytes+diff. BC... Weekly for 18 weeks Fortnightly till 1 year Monthly
101
ANTIPSYCHOTICS- MONITORING? WEIGHT? FBG/HBA1c/LIPIDS/BLOOD PRESSURE? ECG? FBC/U&Es/LFTs? PROLACTIN?
WEIGHT? Start, weekly 1st 6 weeks, 12 weeks, 1 year, then /year. FBG/HBA1c/LIPIDS/BLOOD PRESSURE? Start, 12 weeks, 1 year, then /year ECG? Before initiation FBC/U&Es/LFTs? Start, then /year PROLACTIN? Start, then /6months then /year
102
ANTIPSYCHOTIC SIDE-EFFECTS? HYPOTENSION? CQ HYPERGLYCAEMIA? CiROQ WEIGHT GAIN? COw NEUROLEPTIC MALIGNANT SYNDROME?
HYPOTENSION? Clozapine/Quetiapine ``` HYPERGLYCAEMIA? CiROQ Clozapine Risperidone Olanzapine Quetiapine ``` WEIGHT GAIN? COw Clozapine Olanzapine NEUROLEPTIC MALIGNANT SYNDROME? STOP->TREAT W/ BROMOCRIPTINE->SHOULD RESOLVE IN 5-7 DAYS
103
ANTIPSYCHOTIC SIDE-EFFECTS EXTRAPYRAMIDAL S-E? HYPERPROLACTINAEMIA? SEXUAL DYSFUNCTION? CARDIOVASCULAR S-E?
EXTRAPYRAMIDAL S-E? MOST in Group 3 Phenothiazine+Butyrophenones (fluphenazine/haloperidol) HYPERPROLACTINAEMIA? LEAST in Aripiprazole SEXUAL DYSFUNCTION? ALL antipsychotics CARDIOVASCULAR S-E? QT prolongation, MOST common w/ pimozide+haloperidol
104
ATYPICAL 2ND-GEN ANTIPSYCHOTICS?
``` AMISULPRIDE ARIPIPRAZOLE (least side-effects) CLOZAPINE QUETIAPINE RISPERIDONE ```
105
NEVER USE HALOPERIDOL AS ANTI-EMETIC IN PARKINSON'S DISEASE PATIENTS! EPSE
106
SIDE-EFFECTS? BUTYROPHENONES? THIOXANTHENES? DIPHENBUTYLPIPIERIDINE/SUBSTITUTED BENZAMIDE?
``` BUTYROPHENONES? haloperidol high EPSE (g3 similar) ``` THIOXANTHENES? flupentixol Moderate sedation+antimuscarinic effects+EPSEs DIPHENBUTYLPIPIERIDINE/SUBSTITUTED BENZAMIDE? pimozide/sulpiride Reduced sedation+antimuscarinic effects+EPSEs
107
PHENOTHIAZINE 3 GROUPS? GROUP 1? GROUP 2? GROUP 3?
GROUP 1? chlorpromazine, levomepromazine Most sedation GROUP 2? pericyazine Least EPSEs GROUP 3? fluphenazine, prochlorperazine High EPSEs
108
TYPICAL FIRST-GEN ANTIPSYCHOTICS SIDE-EFFECTS?
Block dopamine d2-receptors in the brain Extrapyramidal symptoms Hyperprolactinaemia
109
TYPICAL FIRST GENERATION ANTIPSYCHOTICS- 5 TYPES ``` Phenothiazine? Butyrophenones? Thioxanthenes? Diphenbutypiperidines? Substituded benzamides? ```
``` 5 TYPES? PBTDS Phenothiazine- chlorpromazine, levomepromazine Butyrophenones- haloperidol Thioxanthenes- zuclopenthixol Diphenbutypiperidines- pimozide Substituded benzamides- sulpirie ```
110
PSYCHOSIS+SCHIZOPHRENIA POSITIVE SYMPTOMS? NEGATIVE SYMPTOMS?
POSITIVE SYMPTOMS? Delusions Hallucinations Disorganisation NEGATIVE SYMPTOMS? Social withdrawal Neglect Poor hygiene
111
ANTI-PARKINSONS MEDS Withdrawal? Off periods? Nocturnal Akinesia- 1st line? 2nd line? Hypotension? Sudden onset of sleep?
KEY POINTS? -Do not withdraw medications abruptly -Person has 'off periods' (med wearing off, no longer optimal) due to end of dose deterioration | nocturnal immobility-> use MR prep -Nocturnal akinesia- treat with 1st line: levodopa/oral dopamine receptor agonist, i.e bromocriptine, cabergoline 2nd line: rotigotine Hypotension? Midodrine Sudden onset of sleep? Modafinil
112
ERGOT-DERIVED DOPAMINE RECEPTOR AGONISTS- BC EXAMPLE? SIDE-EFFECTS?
BROMOCRIPTINE/CABERGOLINE SIDE-EFFECTS? FIBROTIC REACTIONS!!! Pulmonary reactions: SOB, chest pain, cough Pericardial reactions: Chest pain
113
What do you do if symptoms are not controlled with a NEDR-A as adjunct to levodopa?
Add EDR-A instead, w/ levodopa
114
COMT INHIBITORS, ET SIDE-EFFECTS?
ENTACAPONE/TOLCAPONE ``` SIDE-EFFECTS? Entacapone- red-brown urine Tolcapone- hepatotoxic Increases sympathetic S-E- increase in CVD events (tachycardia, fast breathing..) ```
115
If patient develops dyskinesia/motor fluctuations w/ optimal levodopa, WHAT DO YOU DO?
Add an adjuvant: - Non-ergotic dopamine receptor agonist (NEDR-A)/monoamine oxidase B inhibitor - COMT inhibitor
116
MONOAMINE-OXIDASE-B INHIBITORS SIDE-EFFECTS?
RASAGILINE/SELEGILINE SIDE-EFFECTS? Hypertensive crisis if given w/ phenylephrine/pseudoephedrine ``` Interacts w/ Tyramine-rich foods: Mature cheese Salami Marmite Yeast Tofu /Meat Yeast Extract Some beers/wines ```
117
NOR-ERGOT-DERIVED DOPAMINE RECEPTORS- PR^2 SIDE-EFFECTS?
PRAMIPEXOLE/ROPINIROLE/ROTIGOTINE ``` SIDE-EFFECTS? Impulse disorders (>>>than Levodopa, MOST likely) Sudden onset of sleep Hypotension (postural- treat w/ Midodrine->Fludrocortisone) ```
118
LEVODOPA Whys is carbidopa/benserazide added? LEVODOPA- SIDE-EFFECTS?
Whys is carbidopa/benserazide added? Prevents breakdown of levodopa before it crosses into the brain LEVODOPA- SIDE-EFFECTS? Impulse disorders: gambling/binge eating/hypersexuality Sudden onset of sleep (treat w/ modafinil) Red urine
119
PARKINSONS DISEASE- FIRST-LINE TREATMENT Motor symptoms decrease quality of life? Motor symptoms does NOT decrease quality of life?
Motor symptoms decrease quality of life? -Levodopa+Carbidopa/Benserazide Motor symptoms does NOT decrease quality of life? - Levodopa - Non-ergot-derived dopamine-receptor (pramipexole, rotigotine) - Monoamine-oxidase-B-inhibitors (rasagilin/selegiline)
120
PARKINSONS Alleviated by?
Alleviated by? Increasing amounts of dopamine
121
INCREASED ACETYLCHOLINE-> PARASYMPATHETIC SIDE-EFFECTS? Symp- fight/flight Parasymp- rest/digest
``` DUMB BELS Diarrhoea Urinary Incontinence Muscle Weakness Bradycardia Bronchospasms Emesis Lacrimation Salivation ``` Stop treatment, treat the dehydration before reinitiating and amend the dose if need be
122
DEMENTIA- TREATMENT MILD-MODERATE DEMENTIA? AChEIs (and side-effects) MODERATE-SEVERE DEMENTIA? AGGRAVATION TREATED W/?
MILD-MODERATE DEMENTIA? AChEIs (and side-effects) Donepezil- neuroleptic malignant syndrome Rivastigmine- GI side-effects (less in transdermal formulation) Galantamine- S-J syndrome (skin reaction, rash) MODERATE-SEVERE DEMENTIA? Memantine AGGRAVATION TREATED W/? Benzodiazepine/Antipsychotics
123
DEMENTIA Alleviated by?
Alleviated by? Increasing amount of acetylcholine
124
LITHIUM- SIDE-EFFECTS/INTERACTIONS NOTE IN LITHIUM OD, HYPERNATRAEMIA is present, be careful, bit like digoxin OD, flip it
Hyponatraemia (higher risk of toxicity)- LOOP/THIA (almost all hypo side-effects because of MOA inhibition of Na+/K+/2Cl- transporter) Salt Imbalance Serotonin Syndrome (SSRIs, Tramadol) Extrapyramidal S-E (Antiemetics, Antipsychotics) QT Prolongation (Macrolides) Renally Cleared Drugs (NSAIDs- Ibuprofen L, risk of toxicity) Reduced Seizure Threshold (Tramadol) Hypokalaemia (diuretics (loop/thiazide), insulin, laxative_
125
LITHIUM- SIDE EFFCETS?
``` Thyroid disorder Nephrotoxicity Rhabdomyolysis QT prolongation Benign Intercranial Hypertension (persistent headache and visual disturbance) 1st Trimester- teratogenic ```
126
LITHIUM- sick+tremor THERAPEUTIC RANGE? ACUTE EPISODE TARGET? MEASURING LEVELS? SIGNS OF TOXICITY?
THERAPEUTIC RANGE? 0.4-1.0mmol/L ACUTE EPISODE TARGET? acute episodes/relapse/sub-syndromal symptoms 0.8-1.0mmol/L MEASURING LEVELS? 12hours after a dose Weekly till stable->/3 months for year 1->/6months after that BUT 65+, /3MONTHS ``` SIGNS OF TOXICITY? REVeNGe Renal Impairment- incontinence Extrapyramidal- tremor Visual- blurred vision Nervous System Disorder- confusion+restlessness GI Disorder- D&V ```
127
BIPOLAR DISORDER- TREATMENT ACUTE? PROPHYLAXIS? CSL
ACUTE? Benzodiazepine (Lorazepam) helps w/ initial symptoms Antipsyschotics (ROQ- Risperidone, Olanzapine, Quetiapine) L? +in Lithium OR Sodium Valproate PROPHYLAXIS? Carbamazepine Sodium Valproate Lithium
128
BIPOLAR DISORDER?
BIPOLAR DISORDER? | Extreme fluctuation between manic (overactive/excitability) & depressive (reclusive/lethargic) phases
129
EPILEPSY- BREASTFEEDING, BABIES MONOTHERAPY vs COMBINED? HIGH PRESENCE IN MILK? RISK OF DROWSINESS? WITHDRAWAL EFFECTS- Mother suddenly stops breast-feeding?
MONOTHERAPY vs COMBINED? Monotherapy- breast-feeding encouraged Combined therapy/RF- specialist advice ``` HIGH PRESENCE IN MILK? PELZ Primidone Ethosuximide Lamotrigine Zonisamide ``` RISK OF DROWSINESS? BP2 Benzodiazepine Phenobarbital Primidone ``` WITHDRAWAL EFFECTS? BP2L Benzodiazepine Phenobarbital Primidone Lamotrigine ``` *BONUS: Monitor infants for: sedation, feeding difficulties, weight gain and developmental milestones
130
FOLIC ACID IN PREGNANCY LOW RISK OF NEURAL TUBE DEFECTS? HIGH RISK OF NEURAL TUBE DEFECTS?
LOW RISK OF NEURAL TUBE DEFECTS? 400mcg OD, before conception+till week 12 pregnancy ``` HIGH RISK OF NEURAL TUBE DEFECTS? PEDS Previous Epileptic Diabetes Sickle cell disease 5mg OD, before conception+till week 12 pregnancy ``` BUT SICKLE CELL DISEASE IS THROUGHOUT!! (POM btw)
131
EPILEPSY- PREGNANCY 4 KEY POINTS?
4 KEY POINTS? Folic acid reduces risk of neural tube defects in first trimester Vitamin K injection administered at birth to minimize risk of neonatal haemorrhage Riskiest drug: Sodium Valproate (PPP) Topiramate: Cleft Palate
132
EPILEPSY- DRIVING 5 RULES STOP... First unprovoked/isolated fit? Established epilepsy? Medication change/withdrawal X drive for how long after last dose? Seizure ocurs then..?
5 RULES? Stop ASAP+inform DVLA First unprovoked/single isolated: 6 months ban Established epilepsy: 1 year seizure-free, no impact on consciousness (+no history of unprovoked) Medication change/withdrawal: Should not drive for 6 months after last dose Seizure occurs: License revoked for 1 year, but early relicense if treatment has been reinstated for 6 month+seizure-free
133
PHENYTOIN THERAPEUTIC RANGE? SIGNS OF TOXICITY?
THERAPEUTIC RANGE? 10-20mg/L ``` SIGNS OF TOXICITY? SsNA()tCH(e)D-V Slurred Speech Nystagmus Ataxia Confusion Hyperglycaemia Double Vision ```
134
CARBAMAZEPINE THERAPEUTIC RANGE? SIGNS OF TOXICITY?
THERAPEUTIC RANGE? 4-12mg/L (Carb, 4 letters, full 12 kind of) ``` SIGNS OF TOXICITY? HANDBAG Hyponatraemia Ataxia Nystagmus Drowsiness Blurred Vision Arrhythmias GI Disturbances ```
135
ANTI-EPILEPTIC SIDE-EFFECTS HYPERSENSITIVITY? CP3La SKIN RASH? BLOOD DYSCRASIA? C.VET.PLZ EYE DISORDER? VT ENCEPHALOPATHY? RESPIRATORY DEPRESSION? GP
``` HYPERSENSITIVITY? CP3La Carbamazepine Phenytoin Phenobarbital Primidone Lamotrigine ``` SKIN RASH? Lamotrigine->Steven-Johnson syndrome ``` BLOOD DYSCRASIA? C.VET.PLZ Carbamazepine Valproate Ethosuximide Topiramate Phenytoin Lamotrigine Zonisamide ``` EYE DISORDER? VT Vigabatrin (reduced visual field) Topiramate (secondary glaucoma) ENCEPHALOPATHY? Vigabatrin RESPIRATORY DEPRESSION? GP Gabapentin Pregabalin
136
ANTI-EPILEPTIC SIDE-EFFECTS CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? DH^2BV CARBAMZEPINE ONLY? PHENYTOIN ONLY? SODIUM VALPROATE ONLY?
``` CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? DH^2BV Depression+Suicide Hepatotoxicity Hypersensitivity Blood Dyscrasia Vitamin D Deficiency (bone pain) ``` CARBAMZEPINE ONLY? Hyponatraemia+Oedema PHENYTOIN ONLY? Coarsening Appearance Facial Hair SODIUM VALPROATE ONLY? PPP (Pregnancy Prevention Programme key) Pancreatitis Teratogenic
137
CYP450 ENZYME Induces? Inhibits?
Induces? causes enzyme to work quicker, decreases conc. of other X drug Inhibits? causes enzyme to work slower, increases conc. of other X drug
138
ANTI-EPILEPTIC INTERACTIONS CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? HIGH-RISK DRUGS, MUST KNOW IT ALL CARBAMAZEPINE ONLY? PHENYTOIN ONLY?
CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? HIGH-RISK DRUGS, MUST KNOW IT ALL Hepatoxicity: amiodarone, itraconazole, macrolides, alcohol CYP inducer (CPPheno) inhibitor (Sodium Valproate) Drugs that lower seizure threshold: Q-TTie! Quinolones (cipro, levo), Tramdaol, Theophylline ``` CARBAMAZEPINE ONLY? Hyponatraemic drug (SSRI, diuretics)+oedema ``` PHENYTOIN ONLY? Anti-folates (Methotrexate, Trimethoprim)
139
ANTI-EPILEPTICS 3 CATEGORIES most to least severe CATEGORY 1? CP3 CATEGORY 2? CL-VOP CATEGORY 3? BEG-LePre
``` CATEGORY 1? Must be brand-specific CP3 Carbamazepine Phenobarbital Phenytoin Primidone ``` ``` CATEGORY 2? Use clinical judgement+patient's factors, CL-VOP Clobazam Clonazepam Lamotrigine Oxcarbazepine Perampanel Rufinamide Topiramate Valproate Zonisamide ``` ``` CATEGORY 3? Unnecessary, Bob's your uncle! BEG-LePre Brivaracetam Ethosuximide Gabapentin Lacosamide Levetiracetam Pregabalin Tiagabine Vigabatrin ```
140
STATUS EPILEPTICUS? >5mins seizure TREATMENT >5mins? >25mins? >45mins? Community/Resus not available?
>5mins? - IV lorazepam (repeat after 10mins (15) if seizure L) preferred - IV diazepam (high risk of thrombophlebitis+absorption too slow!) >25mins? PFP -Phenytoin/Fosphenytoin/Phenobarbital >45mins? TMP Anaesthesia w/.. -Thiopental/Midazolam/ Propofol (unlicensed indication) Community/Resus not available? -Rectal Diazepam/Buccal Midazolam
141
GENERALISED SEIZURES- 1st LINE & 2ND LINE TAM TONIC-CLONIC/ATONIC/TONIC? ABSENCE? MYOCLONIC?
TAM TONIC-CLONIC/ATONIC/TONIC? 1) Sodium Valproate 2) Lamotrigine ABSENCE? 1) Ethousixime or sodium valproate (valp if high risk of generalised tonic-clonic) 2) Lamotrigine MYOCLONIC? 1) Sodium Valproate 2) Topiramate OR Levetiracetam ATONIC? 1) Sodium Valproate 2) Lamotrigine TONIC? 1) Sodium Valproate 2) Lamotrigine Don't give SV in prenmenopause
142
FOCAL SEIZURES 1ST LINE? 2ND LINE?
1ST LINE? CL Carbamazepine/Lamotrigine 2ND LINE? SLO- Sodium Valproate/Levetiracetam/Oxcarbazepine
143
EPILEPSY 2 TYPES OF SEIZURES?
FOCAL | GENERALISED
144
How long to be on an antidepressant after remission?
6 months, after those '4 weeks.'
145
AVOID CYCLIZINE IN PREGNANCY!
146
Miss U, 73 years old is new to the practice. You are currently conducting a meds reconciliation from her previous practice notes. From the notes, you can see that she has been stabilised on a brand of Lithium Citrate for 20 years, and her bloods from the last 3 years all show Lithium being in range. She also has her annual secondary care mental health review with the psychiatry team. How often should Miss U come in for monitoring for her Lithium?
. 3 monthly 3 MONTHS ELDERLY BRUH!
147
Mr L, 58 years old has come into the practice today to see his regular GP. Mr L has recently been experiencing pain in his back. Below is the list of medication Mr L is currently taking. ▪ Priadel 400mg tablets ▪ Levothyroxine 100mg tablets ▪ Olanzapine 10mg tablets What would be the least suitable analgesic to prescribe, considering Mr L’s medication?
NSAIDs, lithium | Ibuprofen increases the concentration of Lithium. Manufacturer advises monitor and adjust dose.
148
Mr S has had Parkinson’s disease for 3 years now and is on Co-Beneldopa to help manage his symptoms. Unfortunately, today he has also been diagnosed with Dementia. Which of the following drugs would be the most appropriate for him to be put on?
Rivastigmine
149
DULOXETINE DRUG CLASS?
SNRI
150
Which of the following drugs below has both opioid agonist and antagonist properties?
BUPRENORPHINE
151
Which of the following antidepressants drugs can increase the risk of bleeding?
SERTRALINE
152
How many weeks can it take for Buspirone to work?
2 weeks
153
How long should a patient receive an anti-psychotic drug before it is deemed as being ‘ineffective’?
4-6 weeks
154
Over how many weeks should the dose of Clozapine be reduced to avoid the risk of rebound psychosis?
1-2 weeks
155
Mrs K Alory comes into the pharmacy to collect her monthly repeat prescription of medications. You are chatting away to her and notice that she’s not her usual self and ask if she is okay. She informs you that she has been putting on weight recently and unsure why. She is not eating any more than normal and is exercising the same amount and believes it may be down the medications. Which of the medications below is likely to have caused Mrs K Alory’s weight gain?
PIZOTIFEN
156
methylphenidate weight?
loss, loss of appetite
157
Which of the following opioids below is likely to exert it affect by being a mu-receptor agonist, and also enhancing serotonergic and adrenergic pathways?
tramadol
158
LITHIUM COUNSELLING?
Patients should be advised to report signs and symptoms of lithium toxicity, hypothyroidism, renal dysfunction (including polyuria and polydipsia), and benign intracranial hypertension (persistent headache and visual disturbance). Maintain adequate fluid intake and avoid dietary changes which reduce or increase sodium intake. Manufacturer advises effective contraception during treatment for women of child bearing potential
159
Mr PD, a 67-year-old who has been admitted to your ward for routine surgery had a past medical history of Parkinson’s disease and hypertension. He currently takes Madopar 250mg TDS and Amlodipine 5mg OM. Mr PD develops dysphagia post-operatively and a BG tube is inserted to facilitate enteral feeding and drug administration. Which of the following statements would be most appropriate for optimising Mr PD’s Madopar therapy?
Mr R’s Madopar® capsules should be switched to the same dose of Madopar® dispersible tablets for administration via the NG tube If dispersible tablets are available, there is no need for opening capsules. This will also become off-label use.
160
A drug has both opioid agonist and antagonist properties. Sublingually, it is an effective analgesic for 6-8 hours. Its effects are only partially reversed by naloxone hydrochloride. Which of the following is the drug most likely to be?
BUPRENORPHINE
161
A drug indicated in the treatment of epilepsy and due to the long half-life and can be given once daily. Which of the following is the drug most likely to be?
Phenobarbital long half life OD dosing
162
hyponatraemia, encourages sodium absorption+lithium
163
SSRI LONGEST HALF LIFE?
FLUOXETINE
164
DRUG WITH LEAST ANTICHOLINERGIC SIDE-EFFECTS?
MIRABEGRON TROSPIUM ALSO USED BRUHHHH
165
methadone, contraceptive, antidepressant to give?
is amitriptyline safe? minor cns effects?
166
codeine, maximum/day?
240mg
167
PHENYTOIN+TRIMETHOPRIM?
both anti-folate, don't take together!!!
168
side-effects of procyclidine?
blurred vision constipation drowsiness urinary retention NOT YELLOW VISION
169
NOT an enzyme inducer?
levetiracetam
170
A dose of 100 mg fluphenazine (deconoate) once every two weeks is equivalent to 160 mg once every two weeks of this drug in its deconoate form
flupentixol?
171
Meniere's disease?
PROCHLORPERAZINE/CINNARIZINE/CYCLIZINE/PROMETHAZINE
172
meniere disease?
prochlo
173
licensed treatment for a patient who has not responded to non-pharmacological interventions to manage the behavioural and psychological symptoms of dementiagapa
flupentixol
174
Acute kidney injury?
gabapentin
175
PD REVIEW?
EVERY 6-12 MONTHS
176
DISulfiram with alcohol?
nausea, flushing, palpitations, arrhythmias, hypotension, respiratory depression, and coma
177
varenicline depression?
stop | gp quickly?
178
best motion sickness?
HYO HYDRO
179
hypersalivation w/ clozapine treatment?
hyoscine hydrobromide
180
LITHIUM MONITORING?
12 hours post-dose weekly till stable then /3 months for year 1 then /6 months after that 65+? ALWAYS /3 MONTHS IRRESPECTIVE
181
CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE INTERACTIONS?
Hepatoxicity: amiodarone, itraconazole, macrolides, alcohol CYP inducer (CPPheno) inhibitor (Sodium Valproate) Drugs that lower seizure threshold: Q-TTie! Quinolones (cipro, levo), Tramdaol, Theophylline
182
midazolam schedule?
schedule 3
183
oramorph 10mg/5ml?
schedule 5
184
oramorph 20mg/ml?
schedule 2
185
TYPICAL FIRST-GEN ANTIPSYCHOTICS?
``` CHLOPROMAZINE, LEVOMEPROMAZINE HALOPERIDOL ZUCLOPENTHIXOL PIMOZIDE SULPIRIDE ```
186
187
EPILEPSY "If a seizure occurs due to a prescribed change or withdrawal of epilepsy treatment, the patient will have their driving license revoked for 1 year; relicensing may be considered earlier if treatment has been reinstated for 6 months and no further seizures have occurred."
188
Opioids, missed 3 days or more?
risk of OD loss of tolerance need to reduce dsoe
189
TRIPTAN MEDICATION, NOT LICENSED IN?
PREGNANT/BREASTFEEDING
190
Naloxone- opioid | Naltrexone- alcohol
191
192
PHENYTOIN FOSPHENYTOIN CARBAMAZEPINE OXCARBAZEPINE PRE-SCREEN FOR?
Test for HLA-B*1502 allele in individuals of Han Chinese or Thai origin (avoid unless no alternative—risk of Stevens-Johnson syndrome in presence of HLA-B*1502 allele)
193
offensive drugs?
194
Smoking and drugs? TACOW
``` Theophylline Aminophylline Clozapine Olanzapine Warfarin ```
195
A distressed patient has come into the hospital after experiencing symptoms of increased anxiety, aggression, and agitation. The patient only takes ramipril and diazepam regularly. Which one of the following medications is most likely to be given to the patient
flumazenil, reverses benzos!!
196
A patient has come into the pharmacy with a headache they have described to be very painful. They have described it as a sudden severe pain alongside a stiff neck, sensitivity to light and double vision. What is this patient experiencing
The patient is describing the symptoms of a subarachnoid haemorrhage which is more specifically differentiated by the stiff neck and the sudden severe onset. This is a medical emergency and the patient should go straight to A&E.
197
Mrs Chloe Phenamine has been taking sertraline 100mg daily for the past 6 months. As she has not seen any improvement, the doctor wants to initiate an alternative treatment. The GP asks which medication would be most suitable. Which medication is recommended
Failure to respond to initial treatment with an SSRI may require an increase in the dose or switching to a different SSRI or mirtazapine
198
A 21-year-old lady has recently been diagnosed with generalised myoclonic seizures. The doctor would like the advice of the pharmacist on which medication would be most appropriate. Which medication would be most appropriate
First line treatment for myoclonic seizures is Sodium Valproate. However, due to the patient’s gender and age, being of childbearing potential, initiating treatment with Sodium Valproate should be avoided. Second line treatment is Topiramate and Levetiracetam.
199
Mr Tim Olol has recently been initiated on Olanzapine for the treatment of schizophrenia. The patient is due to have a few parameters measured. Which of the following is not a monitoring requirement of Olanzapine
NOT COGNITIVE! Monitoring requirements for people taking antipsychotics includes body weight, U&Es, FBCs, blood lipids, blood glucose levels, pulse, blood pressure, ECGs, prolactin levels, and LFTs
200
PROALCTIN MONITORING?
START 6 MONTHS YEARLY
201
A panicked customer has come into the pharmacy saying that someone has been having a seizure at the bus stop nearby. The pharmacist has timed the seizure and it has exceeded 5 minutes. Which medication is the paramedic most likely to administer to the patient on arrival?
As the seizure has lasted over 5 minutes, the patient is experiencing status epilepticus. Where facilities for resuscitation are not immediately available, diazepam can be administered as a rectal solution or midazolam oromucosal solution can be given into the buccal cavity.
202
Mr Hernia, a 75-year-old man is currently in late stages of Parkinson’s disease and is experiencing severe “off periods”. The consultant will want to initiate them on a potent dopamine-receptor agonist administered parenterally by subcutaneous injection. Which medication is being referred to
Apomorphine is a consultant led potent dopamine-receptor agonist which can be helpful in dealing with ‘off’ episodes with levodopa treatment. It is administered parenterally by subcutaneous injection or infusion
203
Mr Mike Conazole has been admitted to hospital after breaking his leg falling off a horse. He has been suffering with severe pain for which the doctor is prescribing morphine sulphate to help with that. Mr Conazole would like to know what sort of side-effects he should expect. Which side-effect is least likely to occur with morphine
Opiates act on the mu-pathway causing dry mouth, constipation, CNS depression, nausea and vomiting, hypotension, urinary retention, and miosis (pupil constriction) NOT ANXIETY!
204
Mrs Laci Dipine has been taking codeine for chronic back pain for a few months but that is not insufficient in terms of managing her pain levels. The doctor has decided to move her onto a moderate opiate, tramadol. The patient would like to know what the side-effects for this medication are. Which of the following is not a side-effect of tramadol?
NOT HYPERTENSION Counselling points of tramadol includes reduced seizure threshold, increased risk of bleeding, psychiatric disorders, and serotonin syndrome. hypotension
205
Miss Val Sartan a 26-year-old married lady has been advised to be started on anti-epileptic therapy after being diagnosed with tonic-clonic seizures. Which of the following anti-epileptics would be the least suitable for the patient?
Sodium valproate is highly teratogenic and must not be used in females of childbearing potential unless the conditions of the Pregnancy Prevention Programme are met, and alternative treatments are ineffective or not tolerated.
206
The pre-registration student was selling a packet of Sumatriptan over-the-counter and was unsure as to when the medication was contraindicated. Which of the following scenarios would mean that supplying sumatriptan should be avoided
HYPERTENSION Sumatriptan works by causing vasoconstriction which leads to reduced pain. Therefore, patients with cardiovascular diseases and hypertension should avoid the use of sumatriptan
207
Mr Olli Stat has been diagnosed with Parkinson’s disease. The patient has had their initial assessment and their motor symptoms has not affected their quality of life. Which medication would not be included in the patient’s treatment plan
Parkinson's disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride). Entacapone is a COMT Inhibitor.
208
ENTACAPONE IS ONLY FOR SIDE-EFFECTS, WITH OPTIMAL LEVODOPA
209
The following benzodiazepines have a legal driving limit: Clonazepam, Oxazepam, Lorazepam, Diazepam, Flunitrazepam and Temazepam (COLD FeeT).
210
Miss Remi Pril, a 23-year-old patient has been diagnosed with depression and is being prescribed with Sertraline. The patient is due to have counselling on the medication. Which of the following points is least likely to be included in the counselling session
GASHBIQ!!! Sertraline can cause insomnia if taken at night. Therefore, the medication should be taken in the morning.
211
A 24-year-old man has had a seizure on the wards which has now lasted 13 minutes. The patient has already been administered IV Lorazepam, but the seizure has not halted. What is the next step to take
Seizures lasting longer than 5 minutes should be treated urgently with intravenous lorazepam (repeated once after 10 minutes if seizures recur or fail to respond). Intravenous diazepam is effective, but it carries a high risk of thrombophlebitis
212
STATUS EPILEPTICUS, >5mins community?
rectal diazepam | buccal midazolam
213
A patient has been taking Rivastigmine for the treatment of dementia for the past 3 weeks. The patient has complained of nausea, diarrhoea, dehydration, and gastrointestinal discomfort since taking the medication. What is the most appropriate action for this patient
Treatment should be interrupted if dehydration resulting from prolonged vomiting or diarrhoea occurs and withheld until resolution. Dose should be amended if necessary. Transdermal administration is less likely to cause side-effects.
214
Mr Bud Esonide, a 45-year-old patient being initiated on Lithium has been advised to have a consultation with the pharmacist. The patient had heard that it was possible for him to overdose on the medication. Which of these symptoms do not create a cause for concern
Signs of toxicity includes vomiting, diarrhoea, visual disturbances, polyuria, muscle weakness, fine tremor increasing to coarse tremor, confusion, drowsiness, restlessness, incontinence, hypernatremia, seizures, and arrhythmias NOT CONSTIPATION!
215
Mr Esonide came into the hospital after 2 weeks of taking medication as the pharmacist had told him to seek medical advice if he experienced any nausea and vomiting due to toxicity. The doctor would like to prescribe an anti-emetic and asked the pharmacist if there was any that should be avoided. Which anti-emetic should be avoided from the list below
Domperidone increases the risk of QT-prolongation when given with lithium. Manufacturer advises avoid
216
AMFETAMINES?
Amfetamines in overdose can cause wakefulness, excessive activity, paranoia, hallucinations, and hypertension followed by exhaustion, convulsions, hyperthermia, and coma
217
A pregnant lady has come into the pharmacy as she has been experiencing severe nausea and vomiting. As nothing can be given to her over the counter, the pharmacist referred the patient to the GP to be prescribed an anti-emetic. What is first line to be prescribed for the lady
If vomiting is severe in pregnancy, short-term treatment with promethazine may be required.
218
4 years later, Mr Oxaban has now been taken off carbamazepine, and has been advised to not drive in accordance with the DVLA’s regulations. How long should the patient refrain from driving for?
The DVLA recommends that patients should not drive during medication changes or withdrawal of antiepileptic drugs, and for 6 months after their last dose
219
The preregistration student was amazed to hear that certain medications can alter the colour of a patient’s urine. Which of the following medications do not cause a change in urine colour?
Amitriptyline has been known to turn urine a green-blue colour. COMT Inhibitors such as entacapone and tolcapone may discolour urine to orange-brown. Levodopa will colour urine red
220
A patient using methadone to treat substance misuse is being converted to buprenorphine and naloxone therapy by the consultant. What might be the for this change in medication
A combination preparation containing buprenorphine with naloxone can be prescribed for patients when there is a risk of dose diversion for parenteral administration
221
A patient has come in with a prescription for amitriptyline as a new medication. The patient is on a lot of medication already, most of which, the amitriptyline will interact with. Which of the following medications from his list is the only one that will not interact with the amitriptyline
Amitriptyline is affected by CYP 450 Enzyme inhibitors and inducers. Carbamazepine, an enzyme inducer, decreases the exposure to amitriptyline as well as adding to the hyponatraemic affect. Both amitriptyline and hyoscine can cause antimuscarinic effects. Both amitriptyline and candesartan can increase the risk of hypotension. Both amitriptyline and pregabalin can have CNS depressant effects, which might affect the ability to perform skilled taskS
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PERICYAZINE LEAST EPSE!
223
TAMOXIFEN INTERACTION?
FLUOXETINE+PAROXETINE
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. Mr Mo Clobemide has come into the pharmacy with a cold and wanted to buy some pseudoephedrine over the counter. After checking the patients PMR, the pharmacist has decided to refuse the sale. Which medication was the reason for the refusal of this sale
– Tranylcypromine as well as other MAO inhibitors should not be given with pseudoephedrine. Pseudoephedrine is predicted to increase the risk of hypertensive crisis when given with MAO inhibitors.
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DO NOT GIVE MAOI WITH?
PHENYLEPHRINE/PSEUDOEPHEDRINE
226
A patient has come into the hospital for an elective hip replacement surgery. Prior to the surgery, the patient is experiencing nausea and vomiting alongside anxiety and a fast heart rate. Which anti-emetic would you recommend being prescribed prior to the surgery?
Lorazepam is used in the case of anticipatory nausea and vomiting related with anxiety
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A patient has come into the pharmacy with a prescription for clarithromycin. On the prescription there was also an anti-emetic prescribed. You have decided to only dispense the antibiotic and refer the patient back to the GP for the anti-emetic due to an interaction. Which anti-emetic was likely to have been prescribed to cause this interaction
Both Macrolides and Domperidone interact to cause QT interval prolongation
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A patient has come into the pharmacy after experiencing some muscle pain from a fall. The patient has requested to buy some ibuprofen capsules to alleviate the pain. On checking the patient’s medical records, they also take sertraline. Which interaction is likely to occur
SSRI+NSAID? GI BLEED!
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SSRI, NSAID, BLEED!
230
AMIODARONE+TCA?
QT prolongation
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. After the hospital admission, Mr Thium was discharged and advised to continue taking Lithium 400mg twice daily. What is the target serum concentration of Lithium for the patient for maintenance
0.4-1 AFTER?
232
VIGABATRIN?
visual defects, yes sir
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UNPROVOKED SEIZURE?
Patients who have had a first unprovoked epileptic seizure or a single isolated seizure must not drive for 6 months; driving may then be resumed, provided the patient has been assessed by a specialist as fit to drive and investigations do not suggest a risk of further seizures.
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sertraline+tramadol?
serotonin syndrome
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sertraline+ibuprofen?
bleed
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lithium+amitriptyline?
neurotoxicity
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A 55-year-old woman, with breast cancer and taking tamoxifen, is prescribed this antidepressant for menopausal symptoms as per the BNF recommended dose. It is not licensed for this indication.
Venlafaxine is used for menopausal symptoms, but it is not licensed for this indication. Fluoxetine and paroxetine are also used but not for those women on tamoxifen (due to interaction). Venlafaxine is used for menopausal symptoms, but it is not licensed for this indication. Fluoxetine and paroxetine are also used but not for those women on tamoxifen (due to interaction).
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ENZYME INDUCING ANTI EPILEPTICS?
CP3T ``` Carbamazepine. Eslicarbazepine acetate. Oxcarbazepine. Perampanel (at a dose of 12 mg daily or more). Phenobarbital. Phenytoin. Primidone. Rufinamide. Topiramate (at a dose of 200 mg daily or more). ```
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LITHIUM+ ANTIPSYHCO SSRI MAOI
SSRI- QT prolongation MAOI- serotonin syndrome L MAYBE just clozapine?
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LITHIUM+ANTIDEPRESSANTS?
SERTRALINE- SEROTONIN SYNDROME CITALOPRAM- QT PROLONGATION
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VALSARTAN
FALLS
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menopausal symptoms antidepressant?
venlafaxine!
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antiepileptic kidney stones?
topiramate!
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Mrs AK is due an endoscopy in two days’ time. She is extremely anxious about the procedure and the doctor asks for your advice about which benzodiazepine would be most appropriate to give for conscious sedation. Which of the following is the most appropriate choice?
midazolam 2.5mg subcutaneously 5-10 minutes pre-procedure, repeated if necessary
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zopiclone max duration???
6 months
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LITHIUM+BENDROFLUMETHIAZIDE???
HYPONATARAEMIA?!hmm
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• If a person develops moderate or severe bipolar depression and is already taking lithium, check their plasma lithium level. If it is inadequate, increase the dose of lithium; if it is at maximum level, add either fluoxetine combined with olanzapine or add quetiapine, depending on the person's preference and previous response to treatment. - If the person prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to lithium. - If there is no response to adding fluoxetine combined with olanzapine, or adding quetiapine, stop the additional treatment and consider adding lamotrigine to lithium.
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• If a person develops moderate or severe bipolar depression and is already taking lithium, check their plasma lithium level. If it is inadequate, increase the dose of lithium; if it is at maximum level, add either fluoxetine combined with olanzapine or add quetiapine, depending on the person's preference and previous response to treatment

GPhC BNF (48 decks)

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