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GPhC BNF > CNS > Flashcards

CNS Flashcards

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
Q

PARKINSON’S N&V?

A

DOMPERIDONE

Haloperidol/Levmepromazine-> antipsychotics, reduce dopamine levels, L

HYPOTENSION RISK!

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26
Q

PREVENTION & TREATMENT OF POSTOPERATIVE N&V CAUSED BY OPIOIDS/GENERAL ANAESTHETICS?

A

CYCLIZINE

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27
Q

PALLIATIVE CARE N&V?

A

HALOPERIDOL/LEVOMEPROMAZINE

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28
Q

MOTION SICKNESS?

A

hysocine HYDRObromide

hyoscine BUTYLbromide (GI system)

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29
Q

PREOPERATIVE ANTICIPATORY?

A

LORAZEPAM (short-acting)

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30
Q

POSTOPERATIVE N&V?

A

POSTOPERATIVE N&V?

5HT-3 receptor antaognist (Ondansetron)/Dexamethasone

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31
Q

PROPHYLAXIS/TREATMENT OF N&V

PREGNANCY?

SEVERE VOMITING?

A

PREGNANCY?
Nausea in first trimester- generally mild/does not require drug therapy

SEVERE VOMITING?
Short-term treatment-> anithistamine, e.g. promethazine/prochlorperazine/metoclopramide

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32
Q

PROPHYLAXIS/TREATMENT OF N&V?

A

PROPHYLAXIS/TREATMENT OF N&V?
Antihistamines- Cyclizine/Promethazine
Phenothiazines- Prochlorperazine

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33
Q

TENSION HEADACHE

SYMPTOM?

TREATMENT?

A

SYMPTOM?
Bilateral throbbing pain-> tight band around your head

TREATMENT?
Paracetamol/Ibuprofen

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34
Q

TRIGEMINAL NEURALGIA

SYMPTOM?

TREATMENT?

A

SYMPTOM?
Severe facial pain, electric shock-like in jaw/teeth/gums

TREATMENT?
Carbamazepine

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35
Q

CLUSTER HEADACHES TREATMENT

ACUTE?

PROPHYLAXIS? VLP-E

A 
ACUTE?
SC sumatriptan (give nasal sumatriptan/zolmitriptan if unavailable)

PROPHYLAXIS?
Verapamil/Lithium/Prednisolone/Ergotamine tartate (rare)

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36
Q

HEADACHES

CLUSTER SYMPTOM?

A

INTENSE UNILATERAL PAIN IN/AROUND ONE EYE

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37
Q

TRIPTANS CONTRAINDICATED IN..?

A 
IHD
HYPERTENSIONS
PVD
MI
TIA
ANYTHING HEART! (as it narrows blood vessels)
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38
Q

MIGRAINE PROPHYLAXIS

TOPIRAMATE?

A

Caution in women of child-bearing potential
Advice on risks during pregnancy
Teratogenic- cleft palate in first trimester

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39
Q

MIGRAINE PROPHYLAXIS

EPISODIC/CHRONIC
Unlicensed Treatment?
Limited Evidence?

A

EPISODIC/CHRONIC?
UNLICENSED- SODIUM VALPROATE/FLUNARIZINE
Limited evidence- PIZOTIFEN

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40
Q

MIGRAINE PROPHYLAXIS

AMITRIPTYLINE is effective BUT if not tolerated..?

A

AMITRIPTYLINE is effective BUT if not tolerated..?

Use less sedating TCA

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41
Q

MIGRAINE PROPHYLAXIS

1st LINE?
2nd LINE?

A

1st LINE? PROPRANOLOL

2nd LINE? METOPROLOL/NADOLOL

VALPROATE/PIZOTIFEN/BOTOX ALSO USED…

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42
Q

ACUTE MIGRAINE

ANTIEMETICS?

A

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)

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43
Q

ACUTE MIGRAINE

Unable to take first-line options?

A

Give souble paracetamol

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44
Q

ACUTE MIGRAINE

W/ AURA?

REPEAT?

A

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)

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45
Q

MIGRAINE

ACUTE TREATMENT 1ST LINE?

A

ACUTE TREATMENT?
Aspirin/Ibuprofen/5HT-1 receptor agonist (Sumatriptan favoured)
take as soon as patient knows they’ve got a migraine

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46
Q

MIGRAINE

LIFESTYLE ADVICE?

A 
LIFESTYLE ADVICE?
Maintain hydration/sleep/exercise
Avoid chocolate+wine
Relax after stress
Headache diary- identify triggers
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47
Q

MIGRAINE

W/ AURA SYMPTOMS?

A

W/ AURA SYMPTOMS?
Visual (zigzag/flickering lights, spots, lines)
Sensory (pins & needles, numbness)
Dysphasia

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48
Q

MIGRRAINES

SYMPTOMS?

A

Unilateral/pulsating

N&V, photophobia & phonophobia

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49
Q

OPIOID DEPENDENCE

METHADONE?

A

METHADONE?
Causes QT prolongation
Carefully titrate according to patient’s needs

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50
Q

OPIOID DEPENDENCE

x4 BUPRENORPHINE KEY POINTS?

A 
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
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51
Q

OPIOID DEPENDENCE?

High risk of overdose?

A

High risk of overdose? Naloxone

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52
Q

OPIOID DEPENDENCE

PREGNANCY?

A

PREGNANCY? Continue treatment

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53
Q

OPIOID DEPENDENCE

MISSED 3 DAYS OR MORE?

A

MISSED 3 DAYS OR MORE? Risk of OD, loss of tolernace, consider reducing dose, refer to specialist

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54
Q

OPIOID DEPENDENCE

Prescribed on form?

A

Prescribed on form? FP10MDA-> max. supply of 14 days

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55
Q

NICOTINE DEPENDENCE

NICOTINE-REPLACEMENT THERAPY (NRT)?

A

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

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56
Q

NICOTINE DEPENDENCE

BUPROPION?

A

BUPROPION?

Avoid in psychiatric illness/seizures/eating disorders

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57
Q

NICOTINE DEPENDENCE

VARENICLINE?

A

VARENICLINE?

Avoid in epilepsy/cardiovascular disease/psychiatric illness

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58
Q

ALCOHOL DEPENDENCE

WERNICKE’S ENCEPHALOPATHY TREATMENT?

A

WERNICKE’S ENCEPHALOPATHY TREATMENT? Thiamine (Vitamin B1)

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59
Q

ALCOHOL DEPENDENCE

DELIRIUM TREATMENT?

A

DELIRIUM TREATMENT? Lorazepam

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60
Q

ALCOHOL DEPENDENCE

WITHDRAWAL SYMPTOMS TREATMENT?

A

WITHDRAWAL SYMPTOMS TREATMENT?

L-A benzodiazepine, e.g. Chlordiazepoxide/Diazepam (alternative: carbamazepine/clomethiazole)

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61
Q

ALCOHOL DEPENDENCE

TREAT WITH?

A

TREAT WITH? CBT->Acamprosate/Naltrexone (alternative: disulfram)

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62
Q

SUBSTANCE DEPENDENCE

ALCOHOL DEPENDENCE

MILD?

MODERATE?

SEVERE?

A

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

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63
Q

LISDEXAMFETAMINE & DEXAMFETAMINE

OVERDOSE signs?

TREATMENT?

A

OVERDOSE?
Amfetamines cause: wakefulnness/excessive activity/paranoia/hallucinations/hypertension
Followed by: exhaustion/convulsions/hyperthermia/coma

TREATMENT? diazepam/lorazepam

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64
Q

LISDEXAMFETAMINE & DEXAMFETAMINE

SIDE-EFFECTS & MONITORING?
Similar to METHYLPHENIDATE

A
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65
Q

METHYLPHENIDATE

SIDE-EFFECTS?

MONITOR? BPPAWH

A 
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
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66
Q

ADHD

MR-prep preferred?

A 
MR-prep preferred?
Because of their..
pharmacokinetic profile
convenience
improved adherence

PRESCRIBE AS BRAND ONLY

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67
Q

ADHD- ADULT TREATMENT

1st LINE?

2nd LINE?

A

1st LINE?
Use methylphenidate/lisdexamfetamine (dexamfetamine if patient can’t tolerate long duration of action)

2nd LINE?
Atomoxetine (causes QT prolongation, hepatotoxicity & suicidal ideation

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68
Q

ADHD

Children intolerant of both methylphenidate & lisdexamfetamine?

A

Children intolerant of both methylphenidate & lisdexamfetamine?
Atomoxetine
Guanfacine (unlicensed)

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69
Q

ADHD

> /= 5years?

A

> /= 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)

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70
Q

Z-HYPNOTICS

Benzodiazepines+Z-drugs?

SIDE-EFFECTS? PD^2

A

Benzodiazepines (clonazepam/lorazepam)+Z-drugs? Avoid in elderly due to risks of fall and injury

SIDE-EFFECTS? PD^2
Paradoxical side-effects
Drowsiness
Dependance

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71
Q

Z-HYPNOTICS

Examples?
Increases GABA?
Dependency?
When to take it?
Max. duration?
A

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.

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72
Q

BENZODIAZEPINES

SHORT-ACTING BENZODIAZEPINES? LLT

A

SHORT-ACTING BENZODIAZEPINES? Loporazolam/Lormetazepam/Temazepam
Little/no hangover effects
Used for sleep onset
Higher chance of withdrawal symptoms

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73
Q

BENZODIAZEPINES

LONG-ACTING BENZODIAZEPINE? NDF sleep

A

LONG-ACTING BENZODIAZEPINE? Nitrazepam/Diazepam/Fluarazepam
Higher hangover effect following day
Used for sleep maintenance

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74
Q

BENZODIAZEPINES

LONG-ACTING BENZODIAZEPINE? ADC^2

A

ALPRAZOLAM
DIAZEPAM
CHLORDIAZEPOXIDE HYDROCHLORIDE
CLOBAZAM

Can induce hepatic coma, especially long-acting benzodiazepines

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75
Q

SLEEP DISORDERS

CHRONIC INSOMINA?

A

CHRONIC INSOMNIA? cause: anxiety/depression/alcohol/drug abuse
Treat underlying psychiatric complaint

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76
Q

SLEEP DISORDERS

SHORT-TERM INSOMNIA?

A

SHORT-TERM INSOMNIA? emotional problem/serious medical illness
Hypnotic is useful, don’t give more than 3 weeks (1 week ideal)

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77
Q

SLEEP DISORDERS

TRANSIENT INSOMNIA?

A

TRANSIENT INSOMNIA? external factors- noise, shift work & jet lag
Give rapidly eliminated hypnotic- only 1/2 doses

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78
Q

SLEEP DISORDERS

TRANSIENT INSOMNIA?

A

TRANSIENT INSOMNIA? external factors- noise, shift work & jet lag
Give rapidly eliminated hypnotic- only 1/2 doses

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79
Q

MAO-I Washout Periods

Don’t start MAOI until…

A

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)
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80
Q

MAO-I Washout Periods

Other antidepressants should not be started…

A

Other antidepressants should not be started…

For 2 weeks after treatment with MAOIs (3 weeks if clomipramine/imipramine)

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81
Q

x5 MAO-INHIBITORS KEY POINTS?

A

Specialist use

Causes hepatoxicity
(phenelzine+isocarboxazid)

Hypertensive crisis- DO NOT GIVE OTC pseudoephedrine

AVOID tyramine-rich foods
Tranylcypromine+Clomipramine= FATAL

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82
Q

TRICYCLIC ANTIDEPRESSANTS- INTERACTIONS?

A

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

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83
Q

TRICYCLIC ANTIDEPRESSANTS

SIDE-EFFECTS? CASHH

A 
SIDE-EFFECTS? CASHH
Cardiac events
Anti-muscarinic
Seizures
Hypotension
Hallucinations

DANGEROUS IN OVERDOSE

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84
Q

TRICYCLIC ANTIDEPRESSANTS

DANGEROUS OD?

A

DANGEROUS OD?

Amitriptyline/Dosulepin- dangerous in overdose, not recommended for depression, specialist-led!

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85
Q

TRICYCLIC ANTIDEPRESSANTS

LESS SEDATING? NIL

A

LESS SEDATING? better for withdrawn/apathetic patients
Nortriptyline
Imipramine
Lofepramine

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86
Q

TRICYCLIC ANTI-DEPRESSANTS

SEDATING? Better for who?
A
C
D
T
A 
SEDATING? better for agitated/anxious patients
Amitriptyline
Clomipramine
Dosulepin
Trazodone
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87
Q

WHAT IS SEROTONIN SYNDROME? CAN

CAUSED BY?

A

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
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88
Q

SSRIs- INTERACTIONS?

C^2QBHS

A

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

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89
Q

SSRIs- SIDE EFFECTS? GASHBIQ

A 
GASHRIQ
GI Disturbances
Appetitite/Weight Gain
Sexual Dysfunction
Hyponatraemia
Bleed (avoid NSAIDs, warfarin, PPI key)
Insomnia (take OM)
QT Prolongation (Escitalopram/Citalopram)
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90
Q

SSRIs- x3 KEY POINTS?

A

Better tolerated
Safer in OD
Safest in patients w/ cardiac events

SERTRALINE= SAFE, CVD

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91
Q

Depression 5-17 years, SSRI?

A

Fluoxetine

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92
Q

DEPRESSION- TREATMENT?

1st line?

DOES NOT WORK?

A

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

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93
Q

DEPRESSION

MILD?

MODERATE-SEVERE?

A

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

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94
Q

DEPRESSION is?

A

A reduction of serotonin/dopamine/norephedrine at the synaptic cleft

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95
Q

BENZODIAZEPINES- WITHDRAWAL

Withdrawal symptoms?

3 STEPS?

A

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)

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96
Q

BENZODIAZEPINE SIDE-EFFECTS?

COLD FT LEGAL LIMIT?

OD TREATMENT?

A
  • 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

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97
Q

BENZODIAZEPINES-

CAN INDUCE?

LONG-ACTING?

SHORT-ACTING?

A

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)

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98
Q

ANXIETY- TREATMENT

ACUTE?

CHRONIC?

A

ACUTE? Lorazepam/Diazepam- short term use, lowest dose

CHRONIC?
SSRIs- sertraline, citalopram, fluoxetine
Propranolol- alleviates physical symptoms only

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99
Q

CLOZAPINE- SIDE-EFFECTS?

A

MAG
Myocarditis+Cardiomyopathy- report+stop on tachycardia
Agranulocytosis+Neutropenia- monitor leucoyes+diff. BC (report infection symptoms)
GI Disturbances: report+stop on constipation->intestinal block

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100
Q

CLOZAPINE- HIGH-RISK DRUG

USED IN? WHEN?

MISSED MORE THAN 2 DOSES?

MONITOR X? WHEN?

A

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
Q

ANTIPSYCHOTICS- MONITORING?

WEIGHT?

FBG/HBA1c/LIPIDS/BLOOD PRESSURE?

ECG?

FBC/U&Es/LFTs?

PROLACTIN?

A

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
Q

ANTIPSYCHOTIC SIDE-EFFECTS?

HYPOTENSION? CQ

HYPERGLYCAEMIA? CiROQ

WEIGHT GAIN? COw

NEUROLEPTIC MALIGNANT SYNDROME?

A

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
Q

ANTIPSYCHOTIC SIDE-EFFECTS

EXTRAPYRAMIDAL S-E?

HYPERPROLACTINAEMIA?

SEXUAL DYSFUNCTION?

CARDIOVASCULAR S-E?

A

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
Q

ATYPICAL 2ND-GEN ANTIPSYCHOTICS?

A 
AMISULPRIDE
ARIPIPRAZOLE (least side-effects)
CLOZAPINE
QUETIAPINE
RISPERIDONE
105
Q

NEVER USE HALOPERIDOL AS ANTI-EMETIC IN PARKINSON’S DISEASE PATIENTS! EPSE

A
106
Q

SIDE-EFFECTS?

BUTYROPHENONES?

THIOXANTHENES?

DIPHENBUTYLPIPIERIDINE/SUBSTITUTED BENZAMIDE?

A 
BUTYROPHENONES? haloperidol
high EPSE (g3 similar)

THIOXANTHENES? flupentixol
Moderate sedation+antimuscarinic effects+EPSEs

DIPHENBUTYLPIPIERIDINE/SUBSTITUTED BENZAMIDE? pimozide/sulpiride
Reduced sedation+antimuscarinic effects+EPSEs

107
Q

PHENOTHIAZINE 3 GROUPS?

GROUP 1?

GROUP 2?

GROUP 3?

A

GROUP 1? chlorpromazine, levomepromazine
Most sedation

GROUP 2? pericyazine
Least EPSEs

GROUP 3? fluphenazine, prochlorperazine
High EPSEs

108
Q

TYPICAL FIRST-GEN ANTIPSYCHOTICS SIDE-EFFECTS?

A

Block dopamine d2-receptors in the brain
Extrapyramidal symptoms
Hyperprolactinaemia

109
Q

TYPICAL FIRST GENERATION ANTIPSYCHOTICS- 5 TYPES

Phenothiazine?
Butyrophenones?
Thioxanthenes?
Diphenbutypiperidines?
Substituded benzamides?
A 
5 TYPES? PBTDS
Phenothiazine- chlorpromazine, levomepromazine
Butyrophenones- haloperidol
Thioxanthenes- zuclopenthixol
Diphenbutypiperidines- pimozide
Substituded benzamides- sulpirie
110
Q

PSYCHOSIS+SCHIZOPHRENIA

POSITIVE SYMPTOMS?

NEGATIVE SYMPTOMS?

A

POSITIVE SYMPTOMS?
Delusions
Hallucinations
Disorganisation

NEGATIVE SYMPTOMS?
Social withdrawal
Neglect
Poor hygiene

111
Q

ANTI-PARKINSONS MEDS

Withdrawal?

Off periods?

Nocturnal Akinesia-
1st line?
2nd line?

Hypotension?

Sudden onset of sleep?

A

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
Q

ERGOT-DERIVED DOPAMINE RECEPTOR AGONISTS- BC EXAMPLE?

SIDE-EFFECTS?

A

BROMOCRIPTINE/CABERGOLINE

SIDE-EFFECTS? FIBROTIC REACTIONS!!!
Pulmonary reactions: SOB, chest pain, cough
Pericardial reactions: Chest pain

113
Q

What do you do if symptoms are not controlled with a NEDR-A as adjunct to levodopa?

A

Add EDR-A instead, w/ levodopa

114
Q

COMT INHIBITORS, ET

SIDE-EFFECTS?

A

ENTACAPONE/TOLCAPONE

SIDE-EFFECTS?
Entacapone- red-brown urine
Tolcapone- hepatotoxic
Increases sympathetic S-E- increase in CVD events
(tachycardia, fast breathing..)
115
Q

If patient develops dyskinesia/motor fluctuations w/ optimal levodopa, WHAT DO YOU DO?

A

Add an adjuvant:

  • Non-ergotic dopamine receptor agonist (NEDR-A)/monoamine oxidase B inhibitor
  • COMT inhibitor
116
Q

MONOAMINE-OXIDASE-B INHIBITORS

SIDE-EFFECTS?

A

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
Q

NOR-ERGOT-DERIVED DOPAMINE RECEPTORS- PR^2

SIDE-EFFECTS?

A

PRAMIPEXOLE/ROPINIROLE/ROTIGOTINE

SIDE-EFFECTS?
Impulse disorders (>>>than Levodopa, MOST likely)
Sudden onset of sleep
Hypotension (postural- 
treat w/ Midodrine->Fludrocortisone)
118
Q

LEVODOPA

Whys is carbidopa/benserazide added?

LEVODOPA- SIDE-EFFECTS?

A

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
Q

PARKINSONS DISEASE- FIRST-LINE TREATMENT

Motor symptoms decrease quality of life?

Motor symptoms does NOT decrease quality of life?

A

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
Q

PARKINSONS

Alleviated by?

A

Alleviated by? Increasing amounts of dopamine

121
Q

INCREASED ACETYLCHOLINE-> PARASYMPATHETIC SIDE-EFFECTS?

Symp- fight/flight
Parasymp- rest/digest

A 
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
Q

DEMENTIA- TREATMENT

MILD-MODERATE DEMENTIA? AChEIs (and side-effects)

MODERATE-SEVERE DEMENTIA?

AGGRAVATION TREATED W/?

A

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
Q

DEMENTIA

Alleviated by?

A

Alleviated by? Increasing amount of acetylcholine

124
Q

LITHIUM- SIDE-EFFECTS/INTERACTIONS

NOTE IN LITHIUM OD, HYPERNATRAEMIA is present, be careful, bit like digoxin OD, flip it

A

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
Q

LITHIUM- SIDE EFFCETS?

A 
Thyroid disorder
Nephrotoxicity
Rhabdomyolysis
QT prolongation
Benign Intercranial Hypertension (persistent headache and visual disturbance)
1st Trimester- teratogenic
126
Q

LITHIUM- sick+tremor

THERAPEUTIC RANGE?

ACUTE EPISODE TARGET?

MEASURING LEVELS?

SIGNS OF TOXICITY?

A

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
Q

BIPOLAR DISORDER- TREATMENT

ACUTE?

PROPHYLAXIS? CSL

A

ACUTE?
Benzodiazepine (Lorazepam) helps w/ initial symptoms

Antipsyschotics (ROQ- Risperidone, Olanzapine, Quetiapine) L? +in Lithium OR Sodium Valproate

PROPHYLAXIS?
Carbamazepine
Sodium Valproate
Lithium

128
Q

BIPOLAR DISORDER?

A

BIPOLAR DISORDER?

Extreme fluctuation between manic (overactive/excitability) & depressive (reclusive/lethargic) phases

129
Q

EPILEPSY- BREASTFEEDING, BABIES

MONOTHERAPY vs COMBINED?

HIGH PRESENCE IN MILK?

RISK OF DROWSINESS?

WITHDRAWAL EFFECTS- Mother suddenly stops breast-feeding?

A

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
Q

FOLIC ACID IN PREGNANCY

LOW RISK OF NEURAL TUBE DEFECTS?

HIGH RISK OF NEURAL TUBE DEFECTS?

A

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
Q

EPILEPSY- PREGNANCY

4 KEY POINTS?

A

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
Q

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..?

A

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
Q

PHENYTOIN

THERAPEUTIC RANGE?

SIGNS OF TOXICITY?

A

THERAPEUTIC RANGE?
10-20mg/L

SIGNS OF TOXICITY? SsNA()tCH(e)D-V
Slurred Speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia
Double Vision
134
Q

CARBAMAZEPINE

THERAPEUTIC RANGE?

SIGNS OF TOXICITY?

A

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
Q

ANTI-EPILEPTIC SIDE-EFFECTS

HYPERSENSITIVITY? CP3La

SKIN RASH?

BLOOD DYSCRASIA? C.VET.PLZ

EYE DISORDER? VT

ENCEPHALOPATHY?

RESPIRATORY DEPRESSION? GP

A 
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
Q

ANTI-EPILEPTIC SIDE-EFFECTS

CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? DH^2BV

CARBAMZEPINE ONLY?

PHENYTOIN ONLY?

SODIUM VALPROATE ONLY?

A 
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
Q

CYP450 ENZYME

Induces?

Inhibits?

A

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
Q

ANTI-EPILEPTIC INTERACTIONS

CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? HIGH-RISK DRUGS, MUST KNOW IT ALL

CARBAMAZEPINE ONLY?

PHENYTOIN ONLY?

A

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
Q

ANTI-EPILEPTICS 3 CATEGORIES most to least severe

CATEGORY 1? CP3

CATEGORY 2? CL-VOP

CATEGORY 3? BEG-LePre

A 
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
Q

STATUS EPILEPTICUS? >5mins seizure
TREATMENT

> 5mins?

> 25mins?

> 45mins?

Community/Resus not available?

A

> 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
Q

GENERALISED SEIZURES- 1st LINE & 2ND LINE
TAM

TONIC-CLONIC/ATONIC/TONIC?

ABSENCE?

MYOCLONIC?

A

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
Q

FOCAL SEIZURES

1ST LINE?

2ND LINE?

A

1ST LINE?
CL
Carbamazepine/Lamotrigine

2ND LINE?
SLO- Sodium Valproate/Levetiracetam/Oxcarbazepine

143
Q

EPILEPSY

2 TYPES OF SEIZURES?

A

FOCAL

GENERALISED

144
Q

How long to be on an antidepressant after remission?

A

6 months, after those ‘4 weeks.’

145
Q

AVOID CYCLIZINE IN PREGNANCY!

A
146
Q

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?

A

. 3 monthly

3 MONTHS ELDERLY BRUH!

147
Q

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?

A

NSAIDs, lithium

Ibuprofen increases the concentration of Lithium. Manufacturer advises monitor and adjust dose.

148
Q

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?

A

Rivastigmine

149
Q

DULOXETINE DRUG CLASS?

A

SNRI

150
Q

Which of the following drugs below has both opioid agonist and antagonist properties?

A

BUPRENORPHINE

151
Q

Which of the following antidepressants drugs can increase the risk of bleeding?

A

SERTRALINE

152
Q

How many weeks can it take for Buspirone to work?

A

2 weeks

153
Q

How long should a patient receive an anti-psychotic drug before it is deemed as being
‘ineffective’?

A

4-6 weeks

154
Q

Over how many weeks should the dose of Clozapine be reduced to avoid the risk of rebound
psychosis?

A

1-2 weeks

155
Q

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?

A

PIZOTIFEN

156
Q

methylphenidate weight?

A

loss, loss of appetite

157
Q

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?

A

tramadol

158
Q

LITHIUM COUNSELLING?

A

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
Q

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?

A

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
Q

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?

A

BUPRENORPHINE

161
Q

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?

A

Phenobarbital
long half life
OD dosing

162
Q

hyponatraemia, encourages sodium absorption+lithium

A
163
Q

SSRI LONGEST HALF LIFE?

A

FLUOXETINE

164
Q

DRUG WITH LEAST ANTICHOLINERGIC SIDE-EFFECTS?

A

MIRABEGRON

TROSPIUM ALSO USED BRUHHHH

165
Q

methadone, contraceptive, antidepressant to give?

A

is amitriptyline safe? minor cns effects?

166
Q

codeine, maximum/day?

A

240mg

167
Q

PHENYTOIN+TRIMETHOPRIM?

A

both anti-folate, don’t take together!!!

168
Q

side-effects of procyclidine?

A

blurred vision
constipation
drowsiness
urinary retention

NOT YELLOW VISION

169
Q

NOT an enzyme inducer?

A

levetiracetam

170
Q

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

A

flupentixol?

171
Q

Meniere’s disease?

A

PROCHLORPERAZINE/CINNARIZINE/CYCLIZINE/PROMETHAZINE

172
Q

meniere disease?

A

prochlo

173
Q

licensed treatment for a patient who has not responded to non-pharmacological
interventions to manage the behavioural and psychological symptoms of dementiagapa

A

flupentixol

174
Q

Acute kidney injury?

A

gabapentin

175
Q

PD REVIEW?

A

EVERY 6-12 MONTHS

176
Q

DISulfiram with alcohol?

A

nausea, flushing, palpitations, arrhythmias, hypotension, respiratory depression, and coma

177
Q

varenicline depression?

A

stop

gp quickly?

178
Q

best motion sickness?

A

HYO HYDRO

179
Q

hypersalivation w/ clozapine treatment?

A

hyoscine hydrobromide

180
Q

LITHIUM MONITORING?

A

12 hours post-dose
weekly till stable
then /3 months for year 1
then /6 months after that

65+? ALWAYS /3 MONTHS IRRESPECTIVE

181
Q

CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE INTERACTIONS?

A

Hepatoxicity: amiodarone, itraconazole, macrolides, alcohol
CYP inducer (CPPheno) inhibitor (Sodium Valproate)
Drugs that lower seizure threshold: Q-TTie! Quinolones (cipro, levo), Tramdaol, Theophylline

182
Q

midazolam schedule?

A

schedule 3

183
Q

oramorph 10mg/5ml?

A

schedule 5

184
Q

oramorph 20mg/ml?

A

schedule 2

185
Q

TYPICAL FIRST-GEN ANTIPSYCHOTICS?

A 
CHLOPROMAZINE, LEVOMEPROMAZINE
HALOPERIDOL
ZUCLOPENTHIXOL
PIMOZIDE
SULPIRIDE
186
Q
A
187
Q

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.”

A
188
Q

Opioids, missed 3 days or more?

A

risk of OD
loss of tolerance
need to reduce dsoe

189
Q

TRIPTAN MEDICATION, NOT LICENSED IN?

A

PREGNANT/BREASTFEEDING

190
Q

Naloxone- opioid

Naltrexone- alcohol

A
191
Q
A
192
Q

PHENYTOIN
FOSPHENYTOIN
CARBAMAZEPINE
OXCARBAZEPINE

PRE-SCREEN FOR?

A

Test for HLA-B1502 allele in individuals of Han Chinese or Thai origin (avoid unless no alternative—risk of Stevens-Johnson syndrome in presence of HLA-B1502 allele)

193
Q

offensive drugs?

A
194
Q

Smoking and drugs? TACOW

A 
Theophylline
Aminophylline
Clozapine
Olanzapine
Warfarin
195
Q

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

A

flumazenil, reverses benzos!!

196
Q

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

A

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
Q

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

A

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
Q

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

A

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
Q

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

A

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
Q

PROALCTIN MONITORING?

A

START
6 MONTHS
YEARLY

201
Q

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?

A

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
Q

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

A

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
Q

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

A

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
Q

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?

A

NOT HYPERTENSION

Counselling points of tramadol includes reduced seizure threshold, increased risk of bleeding,
psychiatric disorders, and serotonin syndrome. hypotension

205
Q

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?

A

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
Q

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

A

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
Q

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

A

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
Q

ENTACAPONE IS ONLY FOR SIDE-EFFECTS, WITH OPTIMAL LEVODOPA

A
209
Q

The following benzodiazepines have a legal driving limit: Clonazepam, Oxazepam, Lorazepam,
Diazepam, Flunitrazepam and Temazepam (COLD FeeT).

A
210
Q

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

A

GASHBIQ!!!

Sertraline can cause insomnia if taken at night. Therefore, the medication should be taken in the
morning.

211
Q

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

A

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
Q

STATUS EPILEPTICUS, >5mins

community?

A

rectal diazepam

buccal midazolam

213
Q

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

A

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
Q

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

A

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
Q

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

A

Domperidone increases the risk of QT-prolongation when given with lithium. Manufacturer advises
avoid

216
Q

AMFETAMINES?

A

Amfetamines in overdose can cause wakefulness, excessive activity, paranoia, hallucinations, and
hypertension followed by exhaustion, convulsions, hyperthermia, and coma

217
Q

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

A

If vomiting is severe in pregnancy, short-term treatment with promethazine may be required.

218
Q

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?

A

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
Q

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?

A

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
Q

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

A combination preparation containing buprenorphine with naloxone can be prescribed for patients
when there is a risk of dose diversion for parenteral administration

221
Q

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

A

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

222
Q

PERICYAZINE LEAST EPSE!

A
223
Q

TAMOXIFEN INTERACTION?

A

FLUOXETINE+PAROXETINE

224
Q

. 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

A

– 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.

225
Q

DO NOT GIVE MAOI WITH?

A

PHENYLEPHRINE/PSEUDOEPHEDRINE

226
Q

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?

A

Lorazepam is used in the case of anticipatory nausea and vomiting related with anxiety

227
Q

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

A

Both Macrolides and Domperidone interact to cause QT interval prolongation

228
Q

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

A

SSRI+NSAID? GI BLEED!

229
Q

SSRI, NSAID, BLEED!

A
230
Q

AMIODARONE+TCA?

A

QT prolongation

231
Q

. 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

A

0.4-1 AFTER?

232
Q

VIGABATRIN?

A

visual defects, yes sir

233
Q

UNPROVOKED SEIZURE?

A

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.

234
Q

sertraline+tramadol?

A

serotonin syndrome

235
Q

sertraline+ibuprofen?

A

bleed

236
Q

lithium+amitriptyline?

A

neurotoxicity

237
Q

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.

A

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).

238
Q

ENZYME INDUCING ANTI EPILEPTICS?

A

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).
239
Q

LITHIUM+
ANTIPSYHCO
SSRI
MAOI

A

SSRI- QT prolongation
MAOI- serotonin syndrome

L

MAYBE just clozapine?

240
Q

LITHIUM+ANTIDEPRESSANTS?

A

SERTRALINE- SEROTONIN SYNDROME

CITALOPRAM- QT PROLONGATION

241
Q

VALSARTAN

A

FALLS

242
Q

menopausal symptoms antidepressant?

A

venlafaxine!

243
Q

antiepileptic kidney stones?

A

topiramate!

244
Q

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?

A

midazolam 2.5mg subcutaneously 5-10 minutes pre-procedure, repeated if necessary

245
Q

zopiclone max duration???

A

6 months

246
Q

LITHIUM+BENDROFLUMETHIAZIDE???

A

HYPONATARAEMIA?!hmm

247
Q

• 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.
A
248
Q

• 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

A

GPhC BNF (48 decks)

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