CNS Flashcards
(174 cards)
1
Q
What are the different types of dementia?
A
-alzheimers
-vascular
-lewy body dementia
-mixed
-frontotemporal
2
Q
which types of drugs should be avoided in patients with dementia?
A
drugs with a high ACB score
3
Q
what treatment options are first line for mild to moderate dementia in alzheimers?
A
donepezil
galantamine
rivastigmine
(anticholinesterase inhibitors)
4
Q
what would be a suitable alternative to anticholinesterase inhibitors for a patient with moderate alzheimers?
A
memantine
5
Q
what treatment option is indicated for severe alzheimers disease?
A
memantine
6
Q
what are the treatment options for lewy body alzheimers?
A
donepezil or rivastigmine first line if mild-moderate/ donepezil if severe
galantamine if both not tolerated
memantine if none suitable
7
Q
what are the treatment options for vascular dementia?
A
should only be treated if also affected by alzhemiers, lewy body or parkinsons associated dementia
8
Q
when should antipsychotics be offered to patients with dementia?
A
only if they are at risk of harming themselves or others, or experiencing agitation or hallucinations which is causing more distress
9
Q
What is the MHRA alert in regards to use of antipsychotics in patients with dementia?
A
increased risk of stroke and death
10
Q
what three medications used in dementia are anticholinesterase inhibitors?
A
donepezil, galantamine and rivastigmine
11
Q
when should donepezil be taken?
A
at night - sundowning
12
Q
what are the cautions for anticholinesterase inhibitors?
A
bradycardia, heart block, syncope
13
Q
which of the anticholinesterase inhibitors is associated with neuroleptic malignant syndrome? and what are the symptoms of this?
A
donepezil - especially with concomitant antipsychotic use
fever, rigidity, unstable BP
14
Q
what is the major side effect associated with galantamine that would require stopping treatment urgently?
A
skin reaction
15
Q
what are the side effects of anticholinesterase inhibitors?
A
diarrhoea, urination, muscle weakness/ cramps, bronchospasm, bradycardia, emesis, lacrimation, salivation
16
Q
which anticholinesterase inhibitor is associated with GI side effects?
A
rivastigmine - prolonged vomiting and diarrhoea can occur, withhold treatment until resolved
17
Q
what type of drug is memantine?
A
dopaminergic NMDA receptor antagonist
18
Q
what drugs are used for anxiety?
A
BZDs (acute)
propranolol
buspirone
SSRIs
19
Q
which of the BZDs are short acting?
A
lorazepam and oxazepam
20
Q
what is the MHRA alert for all BZDs?
A
risk of potentially fatal resp depression
21
Q
which BZDs should be used in elderly?
A
shorter acting - lorazepam and oxazepam
22
Q
how long does buspirone take to work?
A
2 weeks
23
Q
what is the indication for BZD use in anxiety?
A
short term anxiety (2-4 weeks)
24
Q
what are the side effects of BZDs?
A
-paradoxical increase in hostility/ aggression
-overdose
-sedation (avoid alcohol)
25
what are the symptoms of BZD withdrawal?
anxiety, insomnia, weight loss, tremors, sweating
26
how soon after stopping BZDs can withdrawal occur?
short acting - a day
long acting - 3 weeks
27
how would you manage BZD withdrawal?
-switch to equivalent dose of diazepam
-reduce diazepam dose slowly
28
what is first line for ADHD?
methylphenidate
2nd line - lisdexamfetamine
29
What other treatment options are available for ADHD?
atomexatine, dexamfetamine and guanfacine
30
what do you need to monitor with methylphenidate and how often?
weight and height - affects growth
on initiation, dose changes and 6 monthly
31
what are the side effects of methylphenidate?
appetite loss, insomnia, weight loss, increased heart rate and blood pressure, tics and Tourette's syndrome, growth restriction
32
what could be done to avoid growth problems in children taking methylphenidate?
drug-free periods
33
what are the contraindications to methylphenidate?
CVD, hyperthyroidism, hypertension, severe depression, severe bipolar
34
what are three severe side effects to atomoxetine?
-suicidal ideation
-hepatotoxicity
-QT prolongation
35
when should anti-depressants be avoided in patients with bipolar disorder?
- rapid cycling bipolar
- recent history of mania/ hypomania
(consider stopping the antidepressant if mania develops)
36
what groups of drugs can be used in acute manic phases?
-antipsychotics (haloperidol, olanzapine, quetiapine, risperidone)
-Asenapine licensed for moderate - severe manic episodes
-BZDs (behavioural disturbances/ agitation)
37
What long term medications (mood stabilisers) can be used in bipolar disorder?
-lithium
-valproate
-olanzapine (if response in manic episodes)
-carbamazepine (if unresponsive to other drugs)
38
what are the two different lithium salts?
-lithium citrate
-lithium carbonate
39
the effect of lithium can occur up to how long after initiation of treatment?
12 weeks
40
when would valproate be used in bipolar disorder?
- when lithium alone is ineffective
- if lithium is not tolerated/ contraindicated
41
What is the MHRA alerts for sodium valproate?
- risk of suicidal thoughts and behaviour
-contra-indicated in women and girls of childbearing potential unless conditions of pregnancy prevention programme are met
42
What advice should be given to a female patient taking sodium valproate, who attends the community pharmacy and tell you they are either planning on getting pregnant, or already are pregnant?
Advise them to continue taking sodium valproate, but to see their GP urgently
43
how long is a prescription for sodium valproate valid for?
7 days
44
which of the following is not a side effect of sodium valproate?
-blood dyscrasias
-fatal constipation
-hepatotoxicity
-pancreatitis
fatal constipation
-blood dyscrasias (leukopenia, thrombocytopenia - report signs of infection such as fever, sore throat, mouth ulcers AND/OR bruising and bleeding)
-hepatotoxicity (fatal - report signs of vomiting, abdo pain, jaundice, malaise, drowsiness. Should be discontinued if increased prothrombin time and signs of liver problems)
-pancreatitis (report signs of abdo pain, N&V. Should be discontinued)
45
Which of the following medications is most appropriate to use with sodium valproate?
-ciprofloxacin
-itraconazole
-phenobarbital
-atorvastatin
-codeine
codeine
-ciprofloxacin - lowers seizure threshold
-itraconazole - with valproate, increased risk of hepatotoxicity
-phenobarbital - valproate increases drug concentrations of phenobarbital as it is a enzyme inhibitor
-atorvastatin - with valproate, increased risk of hepatotoxicity
46
long term use of lithium has been associated with what? and what monitoring is required to avoid this?
-thyroid disorders (monitor TFTs 6 monthly)
-mild cognitive and memory impairment
47
Why does lithium require intense monitoring and levels to be taken?
it has a narrow therapeutic range
48
what are the signs and symptoms of lithium toxicity?
-renal disturbances (polyuria, incontinence, hyponatraemia)
-extrapyramidal (tremor, ataxia, dysarthria, myoclonus, nystagmus, muscle weakness)
-visual disturbances
-nervous system disturbances (confusion, drowsiness, incoordination, restlessness, stupor)
-GI (diarrhoea and vomiting)
49
when should lithium levels be taken?
12 hours post dose
50
what is the target range of lithium for chronic bipolar treatment vs acute mania?
Chronic bipolar: 0.4 - 1 mmol/L
Acute mania: 0.8 - 1 mmol/L
51
how often should serum lithium monitoring be performed?
after initiation and each dose change, THEN
every 3 months for a year, THEN
6 monthly thereafter
52
doses of lithium over what serum level are associated with renal failure, arrhythmias, circulatory failure, coma and death?
> 2 mmol/L
53
what 4 things should be monitored throughout lithium treatment?
-BMI
-electrolytes
-eGFR
-thyroid
54
what are the side effects of lithium?
-thyroid disorders (hypo and hyper)
-renal impairment
-intracranial hypertension
-QT prolongation
-lowers seizure threshold
55
what electrolyte imbalance predisposes patients to an increased risk of lithium toxicity?
hyponatraemia
56
which of the following medications do not interact with lithium?
-clarithromycin
-ramipril
-furosemide
-sertraline
-ibuprofen
-codeine
codeine
-clarithromycin - QT prolongation
-ramipril - increased concentration of lithium (as lithium is renally cleared)
-furosemide - hyponatraemia
-ibuprofen - ibuprofen increases the concentration of lithium (as lithium is renally cleared)
57
how long should an antidepressant be trialled before considering switching?
4 weeks (6 weeks in elderly)
58
antidepressants are associated with which side effects within the first few weeks of treatment?
agitation, anxiety, suicidal ideation (particularly in younger patients)
59
which class of antidepressants are first line?
SSRIs
60
SSRIs and other antidepressants have been associated with which electrolyte imbalance?
hyponatraemia
61
what are the symptoms of hyponatraemia?
confusion, drowsiness, convulsions
62
what are symptoms of serotonin syndrome?
-neuromuscular (tremor, hyperreflexia, clonus, myoclonus, rigidity)
-autonomic (tachycardia, BP instability, hyperthermia, diaphoresis, shivering, diarrhoea)
-mental (agitation, confusion, mania)
63
why is amitriptyline not recommended for depression?
dangerous in overdose
64
which of the following TCAs are sedative?
-nortriptyline
-amitriptyline
-trazadone
amitriptyline and trazadone
65
Name some MAOIs?
moclobemide, trancylpromine, phenelzine, isocarboxazid
66
when switching between antidepressants, how long should be given before adding in a new therapy?
SSRIs - wait 1 week before switching
TCAs - wait 1-2 weeks before switching
MAOIs - wait 2 weeks before switching
67
which is the only SSRI licensed in children?
fluoxetine
68
which two SSRIs cause QT prolongation?
citalopram and escitalopram
69
which of the SSRIs is safest in MI and unstable angina?
sertraline
70
What is the MHRA alert for all SSRIs and SNRIs?
risk of postpartum haemorrhage if used in month before delivery
71
what are side effects of SSRIs?
GI (N&V, diarrhoea)
appetite or weight disturbance
hypersensitivity
lowers seizure threshold
movement disorders
bleeding risk
72
what are the side effects of TCAs?
cardiac (QT prolongation, arrhythmias, heart block, hypertension)
antimuscarinic (dry mouth, blurred vision, constipation, tachycardia, urinary retention)
seizures
73
what are the side effects of MAOIs?
hepatotoxicity
postural hypotension
hypertensive crisis
74
foods containing what should be avoided with MAOIs?
tyramine rich foods (mature cheese, wine, meat stocks, pickled herring, game, broad bean pods)
Also avoid:
-stale foods
-alcohol
75
what are side effects of mirtazapine?
increased sleepiness
weight gain - increased appetite
advise patient to look out for signs of infection (sore throat, fever)
76
venlafaxine and duloxetine are what type of anti-depressants?
SNRIs
77
what are the negative symptoms associated with schizophrenia?
emotional apathy, social withdrawal
78
what are the positive symptoms associated with schizophrenia?
hallucinations, delusions
79
when would clozapine be offered for schizophrenia?
uncontrolled despite use of at least 2 different antipsychotic drugs
80
how do first generation antipsychotics have an effect in schizophrenia?
predominantly by blocking dopamine receptors in the brain
81
name some first generation antipsychotics?
chlorpromazine, fluphenazine, levomepromazine, prochlorperazine, promazine, haloperidol, flupentixol, pimozide, sulpiride
82
name some second generation antipsychotics?
amisulpride, aripiprazole, asenapine, cariprazine, clozapine, quetiapine, risperidone
83
which of the following is not a side effect of antipsychotics?
-hyperprolactinaemia
-QT prolongation
-hypotension
-hepatotoxicity
-hyperglycaemia
-weight gain
hepatotoxicity
84
what monitoring is required with antipsychotics?
-weight (baseline, weekly for 6 weeks, the at week 12, at year 1, then annually)
-HbA1c and lipids (baseline, week 12, year 1)
-ECG at baseline
-prolactin at baseline
-BP (baseline, week 12, year 1, then annually)
85
what is the MHRA alert for haloperidol?
risk of cardiac and neurological effects when used in elderly patients for delirium
86
what is the MHRA alert for antipsychotics?
monitoring blood concentrations for toxicity
87
what is the MHRA alert for clozapine?
monitoring blood concentrations for toxicity:
-when a patient stops smoking or switches to e-cigarette
-concomitant medicines may interact to cause toxicity
-patient has pneumonia or other severe infection
-reduced clozapine metabolism
88
which two antipsychotics can be affected by smoking? and how?
clozapine and olanzapine - smoking decreases levels requiring increase increase in dose
Tobacco Can Avoid Overdose
Theophylline
Clozapine
Olanzapine
Aminophylline
89
when administering antipsychotics in an emergency, which route should be used?
IM - smaller dose than oral
90
What are the severe side effects of clozapine? and how do you manage these?
Agranulocytosis - every week for 18 weeks, then fortnightly for a year, then monthly
Constipation - can be fatal - counsel
myocarditis/ cardiomyopathy (tachy for first 2 months, stop permanently if cardiomyopathy or endocarditis)
91
what indication is clozapine licensed for?
resistant schizophrenia
(must have tried 2 or more drugs for at least 6-8 weeks)
92
If more than 2 doses of clozapine have been missed, what should be done?
should be reinitiated
93
which is the only antipsychotic not associated with prolactinaemia?
aripiprazole
94
what is the treatment for neuroleptic malignant syndrome?
bromocriptine or dantrolene
95
what motor symptoms are associated with PD?
hypokinesia, bradykinesia, rigidity, tremor, postural instability
96
what non-motor symptoms are associated with PD?
dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing difficulties, weight loss
97
In PD patients whose motor symptoms are affecting their quality of life, what should they be offered?
Co-careldopa (levodopa & carbidopa)
Co-beneldopa (levodopa & benserazide)
98
In PD patients whose motor symptoms do not affect their quality of life, what should they be offered?
Levodopa
Non ergot Dopamine agonists (pramipexole, ropinirole, rotigotine)
MAOB inhibitors (rasagline, selegline)
99
In PD patients whose symptoms are not well controlled despite optimal therapy with levodopa, what can be added?
Non ergot Dopamine agonists
MAOB inhibitors
COMT inhibitors (entacapone, opicapone, tolcapone)
Ergot dopamine agonists (bromocriptine, cabergoline, pergolide) - only if non-ergot ineffective
100
what drug can be added on in patients with advanced PD?
apomorphine (intermittent injections or CSCI)
101
when initiating a patient on apomorphine, what additional drug is recommedned?
domperidone - to control N&V associated with apomorphine
should be started two days before apomorphine therapy, then discontinued as soon as possible (INCREASED QT RISK WITH BOTH - ECG)
102
What are the mechanism of action of COMT inhibitors, and how do they help in PD?
they prevent the peripheral breakdown of levodopa, allowing more to reach the brain - useful for end of dose motor fluctuations
103
entacapone may colour your urine what colour?
reddish/ brown
104
what is the caution for tolcapone?
fatal hepatotoxcity
105
what is the brand name of co-careldopa?
sinemet
106
what is the brand name of co-beneldopa?
madopar
107
what is the benefit of using the combination of co-beneldopa and co-careldopa?
benserazide and carbidopa reduce the peripheral side effects of levodopa (nausea, vomiting, cardiovascular) and also allow for lower doses to be used for therapeutic effect
108
what are the side effects of co-careldopa and co-beneldopa?
impulse control (to a less extent than dopamine agonists)
excessive sleepiness/ sudden onset of sleep
motor complications (dyskinesia)
109
why are non ergot dopamine agonists preferred over ergot derived?
ergot dopamine agonists have a high risk of fibrotic reactions:
-pulmonary (dyspnoea, persistent cough)
-retroperitoneal (abdo pain and tenderness)
-pericardial (cardiac failure)
110
what are the side effects of dopamine agonists?
impulse control (gambling, hypersexuality, binge eating)
excessive sleepiness and sudden onset of sleep
psychotic symptoms (hallucinations, delusions)
hypotension reaction in first few days
111
what is the advice surrounding application of the rotigotine patch?
patches should be removed for 24 hours and new patch applied to different area (avoid the same are for 14 days)
112
what is the mechanism of action of MAOB inhibitors?
inhibit the enzyme responsible for the breakdown of dopamine
113
MAOB inhibitors have a risk of hypertensive crisis when combined with which other medications?
-OTC decongestants (pseudoephedrine, xylometazoline ...)
-Medications which increase BP (adrenaline ...)
114
in patients with PD who develop muscle cramps, what medication can b used?
quinine
115
in patients with PD who develop excessive saliva/ drooling, what medication can be used?
glycopyrronium bromide
116
in patients with PD who develop postural hypotension, what medication can be used?
midodrine
117
what is the anti-emetic of choice in PD, and which should be avoided?
domperidone
Metoclopramide should be avoided
118
what is the anti-emetic of choice in pregnancy?
promtheazine (short-term antihistamine)
118
what is the anti-emetic of choice in pregnancy?
promethazine (short-term antihistamine)
if symptoms do not settle after 24-48 hours - specialist
** only treat if severe
119
what are the risk factors for developing post-operative N&V?
female, younger, non-smoker, hx of postop N&V, opioid use
120
what are the anti-emetics of choice for post-op N&V
two anti-emetics with different MoA:
ondansetron/ dexamethasone AND
cyclizine
121
what is the anti-emetic of choice for motion sickness?
hyoscine hydrobromide
122
what is the age restriction and max duration of metoclopramide?
>18 years and max 5 days duration
123
what is the age restriction and max duration of domperidone?
>12 years and max 7 days duration
124
what are the three different types of insomnia and how do you treat these?
Transient (due to environmental factors)- short acting and give only one or two doses
Short-term (emotional problems) - take intermittently and omit some doses - give no more than 3 weeks
Chronic (psychiatric disorders) - treat underlying cause
125
what is the max duration of use of Z drugs for insomnia?
4 weeks
(tolerance develops in 3-14 days of continuous use)
126
which anti-epileptics have long half lives and can be given once daily?
phenytoin
lamotrigine
phenobarbital
127
What is the three MHRA alerts for antiepileptics?
-risk of suicidal thoughts and behaviour
-switching between different brands
-antiepileptic drugs and pregnancy
128
what 4 drugs are category 1 antiepileptics?
carbamazepine, phenobarbital, phenytoin, primdone
129
patients who experience their first unprovoked epileptic seizure are not allowed to drive for how long?
6 months
130
patients with established epilepsy are able to drive if they are seizure free for what length of time?
1 year
131
epileptic patients who have a dose change, or withdrawal of their medication, should not drive for how long?
6 months
132
which two antiepileptics are safer in pregnancy?
lamotrigine and levetiracetam
133
which antiepileptics are unsafe in pregnancy?
valproate, carbamazepine, phenobarbital, topiramate (cleft palate)
134
what is the treatment choice for tonic-clonic seizures?
1st valproate
2nd lamotrigine/ levetiracetam
135
what is the treatment choice for absence seizures?
1st ethosuximide
2nd valproate
136
what is the treatment choice for myoclonic seizures?
1st valproate
alternative - levetiracetam
137
which anti-epileptics should not be used in myoclonic seizures?
carbamazepine, phenytoin
138
what is the treatment choice for atonic/ tonic seizures?
1st valproate
alternative - lamotrigine
139
what is the treatment choice for focal seizures?
1st levetiracetam and lamotrigine
alternative - oxcarbazepine, zonisamide, levetiracetam
140
what advice should be given to epileptic patients who are pregnant?
-risk of harm from seizure outweighs risk of medication
-folic acid in first trimester
-vit K at birth - reduces risk of neonatal haemorrhage
141
which anti-epileptics are associated with SJS?
lamotrigine
142
which anti-epileptics are associated with hyponatraemia?
carbamazepine
143
which anti-epileptics are associated with eye disorder?
topiramate (glaucoma)
144
which anti-epileptics are associated with respiratory depression?
gabapentin and pregabalin
145
which anti-epileptics are associated with blood dyscrasias?
carbamazepine, valproate, ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide
146
what is the MHRA alert for gabapentin and pregabalin?
risk of severe respiratory depression
147
what is the MHRA alert specific to phenytoin?
risk of death and sever harm with injectable phenytoin
148
what is the MHRA alert specific to pregabalin?
risk of abuse and dependency
149
what type of seizures is phenytoin indicated in? and which is it contraindicated in?
indicated for focal, generalised tonic-clonic
exacerbates absence and myoclonic
150
what is the therapeutic range or phenytoin?
10-20mg/L
151
what is phenytoin bound to?
highly protein bound, bound to albumin
152
what is the conversion between phenytoin sodium and phenytoin base?
100mg phenytoin sodium = 92mg phenytoin base
153
what are the signs and symptoms of phenytoin toxicity?
slurred speech
nystagmus
ataxia
confusion
hyperglycaemia
double vision
154
what are the side effects of phenytoin?
coarsening of facial features
blood dyscrasias
skin reactions (SJS increased risk if asian)
low vitamin D
hepatotoxicity
155
what type of seizures is carbamazepine indicated in? and which is it contraindicated in?
indicated for focal and generalised tonic-clonic
exacerbates atonic, clonic, myoclonic
156
what is the therapeutic range of carbamazepine?
4-12 mg/L
measure after 1-2 weeks
157
what are the signs and symptoms of carbamazapine toxicity?
hyponatraemia
ataxia
nystagmus
drowsiness
blurred vision
arrhythmias
GI disturbance
158
what should you monitor for carbamazepine?
FBC, LFTs, renal profile
159
during status epilepticus, if a seizure last longer than 5 minutes, what can be used as treatment?
IV lorazepam
buccal midazolam
rectal diazepam (if in community)
2nd dose can be given after 5-10 minutes if no improvement
160
what is the definition of chronic pain?
pain occurring for longer than 12 weeks
161
what is the licensed age for codeine?
>12 years
contraindicated in patients under 18 who have had their tonsils removed
162
in patients receiving regular strong opioids, what should be the strength of the breakthrough pain relief?
1/6th - 1/10th total daily dose
163
what is first line for an acute migraine attack?
simple analgesic
164
what is second line for an acute migraine attack?
5HT1 agonist (sumatriptan)
(can be repeated after 2 hours but only if shown response to first dose)
165
what can be used as prophylaxis of migraine?
propranolol
amitriptyline
valproate
166
which drugs can be used for opioid dependence?
- methadone
-buprenorphine
167
if the patient misses more than 4 doses of their opioid maintenance therapy, what should you do?
refer
168
what drug should be used to weaken symptoms of alcohol withdrawal?
long acting BZD:
chlordiazepoxide
diazepam
169
what drug should be used for delirium tremens in alcohol withdrawal?
lorazepam
170
what drugs can be used to prevent the risk of alcohol dependence relapse?
acamprosate or naltrexone
171
what should be given to patients at risk of developing wernicke's encephalopathy?
oral thiamine (B1)
172
what drug treatments are options for aiding smoking cessation?
varenicline, bupropion, NRT
173
Which antiepileptics have the highest presence in breastfeeding?
ethosuximide, primidone, lamotrigine, zonisamide
