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Pharmacy > CNS > Flashcards

CNS Flashcards

1
Q

What are the different types of dementia?

A

-alzheimers
-vascular
-lewy body dementia
-mixed
-frontotemporal

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2
Q

which types of drugs should be avoided in patients with dementia?

A

drugs with a high ACB score

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3
Q

what treatment options are first line for mild to moderate dementia in alzheimers?

A

donepezil
galantamine
rivastigmine

(anticholinesterase inhibitors)

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4
Q

what would be a suitable alternative to anticholinesterase inhibitors for a patient with moderate alzheimers?

A

memantine

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5
Q

what treatment option is indicated for severe alzheimers disease?

A

memantine

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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

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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

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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

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9
Q

What is the MHRA alert in regards to use of antipsychotics in patients with dementia?

A

increased risk of stroke and death

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10
Q

what three medications used in dementia are anticholinesterase inhibitors?

A

donepezil, galantamine and rivastigmine

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11
Q

when should donepezil be taken?

A

at night - sundowning

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12
Q

what are the cautions for anticholinesterase inhibitors?

A

bradycardia, heart block, syncope

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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

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14
Q

what is the major side effect associated with galantamine that would require stopping treatment urgently?

A

skin reaction

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15
Q

what are the side effects of anticholinesterase inhibitors?

A

diarrhoea, urination, muscle weakness/ cramps, bronchospasm, bradycardia, emesis, lacrimation, salivation

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16
Q

which anticholinesterase inhibitor is associated with GI side effects?

A

rivastigmine - prolonged vomiting and diarrhoea can occur, withhold treatment until resolved

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17
Q

what type of drug is memantine?

A

dopaminergic NMDA receptor antagonist

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18
Q

what drugs are used for anxiety?

A

BZDs (acute)
propranolol
buspirone
SSRIs

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19
Q

which of the BZDs are short acting?

A

lorazepam and oxazepam

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20
Q

what is the MHRA alert for all BZDs?

A

risk of potentially fatal resp depression

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21
Q

which BZDs should be used in elderly?

A

shorter acting - lorazepam and oxazepam

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22
Q

how long does buspirone take to work?

A

2 weeks

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23
Q

what is the indication for BZD use in anxiety?

A

short term anxiety (2-4 weeks)

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24
Q

what are the side effects of BZDs?

A

-paradoxical increase in hostility/ aggression
-overdose
-sedation (avoid alcohol)

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25
Q

what are the symptoms of BZD withdrawal?

A

anxiety, insomnia, weight loss, tremors, sweating

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26
Q

how soon after stopping BZDs can withdrawal occur?

A

short acting - a day
long acting - 3 weeks

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27
Q

how would you manage BZD withdrawal?

A

-switch to equivalent dose of diazepam
-reduce diazepam dose slowly

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28
Q

what is first line for ADHD?

A

methylphenidate

2nd line - lisdexamfetamine

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29
Q

What other treatment options are available for ADHD?

A

atomexatine, dexamfetamine and guanfacine

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30
Q

what do you need to monitor with methylphenidate and how often?

A

weight and height - affects growth
on initiation, dose changes and 6 monthly

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31
Q

what are the side effects of methylphenidate?

A

appetite loss, insomnia, weight loss, increased heart rate and blood pressure, tics and Tourette’s syndrome, growth restriction

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32
Q

what could be done to avoid growth problems in children taking methylphenidate?

A

drug-free periods

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33
Q

what are the contraindications to methylphenidate?

A

CVD, hyperthyroidism, hypertension, severe depression, severe bipolar

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34
Q

what are three severe side effects to atomoxetine?

A

-suicidal ideation
-hepatotoxicity
-QT prolongation

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35
Q

when should anti-depressants be avoided in patients with bipolar disorder?

A
  • rapid cycling bipolar
  • recent history of mania/ hypomania

(consider stopping the antidepressant if mania develops)

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36
Q

what groups of drugs can be used in acute manic phases?

A

-antipsychotics (haloperidol, olanzapine, quetiapine, risperidone)
-Asenapine licensed for moderate - severe manic episodes
-BZDs (behavioural disturbances/ agitation)

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37
Q

What long term medications (mood stabilisers) can be used in bipolar disorder?

A

-lithium
-valproate
-olanzapine (if response in manic episodes)
-carbamazepine (if unresponsive to other drugs)

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38
Q

what are the two different lithium salts?

A

-lithium citrate
-lithium carbonate

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39
Q

the effect of lithium can occur up to how long after initiation of treatment?

A

12 weeks

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40
Q

when would valproate be used in bipolar disorder?

A
  • when lithium alone is ineffective
  • if lithium is not tolerated/ contraindicated
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41
Q

What is the MHRA alerts for sodium valproate?

A
  • risk of suicidal thoughts and behaviour
    -contra-indicated in women and girls of childbearing potential unless conditions of pregnancy prevention programme are met
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42
Q

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?

A

Advise them to continue taking sodium valproate, but to see their GP urgently

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43
Q

how long is a prescription for sodium valproate valid for?

A

7 days

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44
Q

which of the following is not a side effect of sodium valproate?
-blood dyscrasias
-fatal constipation
-hepatotoxicity
-pancreatitis

A

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)

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45
Q

Which of the following medications is most appropriate to use with sodium valproate?
-ciprofloxacin
-itraconazole
-phenobarbital
-atorvastatin
-codeine

A

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

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46
Q

long term use of lithium has been associated with what? and what monitoring is required to avoid this?

A

-thyroid disorders (monitor TFTs 6 monthly)
-mild cognitive and memory impairment

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47
Q

Why does lithium require intense monitoring and levels to be taken?

A

it has a narrow therapeutic range

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48
Q

what are the signs and symptoms of lithium toxicity?

A

-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)

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49
Q

when should lithium levels be taken?

A

12 hours post dose

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50
Q

what is the target range of lithium for chronic bipolar treatment vs acute mania?

A

Chronic bipolar: 0.4 - 1 mmol/L
Acute mania: 0.8 - 1 mmol/L

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51
Q

how often should serum lithium monitoring be performed?

A

after initiation and each dose change, THEN

every 3 months for a year, THEN

6 monthly thereafter

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52
Q

doses of lithium over what serum level are associated with renal failure, arrhythmias, circulatory failure, coma and death?

A

> 2 mmol/L

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53
Q

what 4 things should be monitored throughout lithium treatment?

A

-BMI
-electrolytes
-eGFR
-thyroid

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54
Q

what are the side effects of lithium?

A

-thyroid disorders (hypo and hyper)
-renal impairment
-intracranial hypertension
-QT prolongation
-lowers seizure threshold

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55
Q

what electrolyte imbalance predisposes patients to an increased risk of lithium toxicity?

A

hyponatraemia

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56
Q

which of the following medications do not interact with lithium?
-clarithromycin
-ramipril
-furosemide
-sertraline
-ibuprofen
-codeine

A

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)

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57
Q

how long should an antidepressant be trialled before considering switching?

A

4 weeks (6 weeks in elderly)

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58
Q

antidepressants are associated with which side effects within the first few weeks of treatment?

A

agitation, anxiety, suicidal ideation (particularly in younger patients)

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59
Q

which class of antidepressants are first line?

A

SSRIs

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60
Q

SSRIs and other antidepressants have been associated with which electrolyte imbalance?

A

hyponatraemia

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61
Q

what are the symptoms of hyponatraemia?

A

confusion, drowsiness, convulsions

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62
Q

what are symptoms of serotonin syndrome?

A

-neuromuscular (tremor, hyperreflexia, clonus, myoclonus, rigidity)
-autonomic (tachycardia, BP instability, hyperthermia, diaphoresis, shivering, diarrhoea)
-mental (agitation, confusion, mania)

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63
Q

why is amitriptyline not recommended for depression?

A

dangerous in overdose

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64
Q

which of the following TCAs are sedative?
-nortriptyline
-amitriptyline
-trazadone

A

amitriptyline and trazadone

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65
Q

Name some MAOIs?

A

moclobemide, trancylpromine, phenelzine, isocarboxazid

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66
Q

when switching between antidepressants, how long should be given before adding in a new therapy?

A

SSRIs - wait 1 week before switching
TCAs - wait 1-2 weeks before switching
MAOIs - wait 2 weeks before switching

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67
Q

which is the only SSRI licensed in children?

A

fluoxetine

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68
Q

which two SSRIs cause QT prolongation?

A

citalopram and escitalopram

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69
Q

which of the SSRIs is safest in MI and unstable angina?

A

sertraline

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70
Q

What is the MHRA alert for all SSRIs and SNRIs?

A

risk of postpartum haemorrhage if used in month before delivery

71
Q

what are side effects of SSRIs?

A

GI (N&V, diarrhoea)
appetite or weight disturbance
hypersensitivity
lowers seizure threshold
movement disorders
bleeding risk

72
Q

what are the side effects of TCAs?

A

cardiac (QT prolongation, arrhythmias, heart block, hypertension)
antimuscarinic (dry mouth, blurred vision, constipation, tachycardia, urinary retention)
seizures

73
Q

what are the side effects of MAOIs?

A

hepatotoxicity
postural hypotension
hypertensive crisis

74
Q

foods containing what should be avoided with MAOIs?

A

tyramine rich foods (mature cheese, wine, meat stocks, pickled herring, game, broad bean pods)

Also avoid:
-stale foods
-alcohol

75
Q

what are side effects of mirtazapine?

A

increased sleepiness
weight gain - increased appetite

advise patient to look out for signs of infection (sore throat, fever)

76
Q

venlafaxine and duloxetine are what type of anti-depressants?

A

SNRIs

77
Q

what are the negative symptoms associated with schizophrenia?

A

emotional apathy, social withdrawal

78
Q

what are the positive symptoms associated with schizophrenia?

A

hallucinations, delusions

79
Q

when would clozapine be offered for schizophrenia?

A

uncontrolled despite use of at least 2 different antipsychotic drugs

80
Q

how do first generation antipsychotics have an effect in schizophrenia?

A

predominantly by blocking dopamine receptors in the brain

81
Q

name some first generation antipsychotics?

A

chlorpromazine, fluphenazine, levomepromazine, prochlorperazine, promazine, haloperidol, flupentixol, pimozide, sulpiride

82
Q

name some second generation antipsychotics?

A

amisulpride, aripiprazole, asenapine, cariprazine, clozapine, quetiapine, risperidone

83
Q

which of the following is not a side effect of antipsychotics?
-hyperprolactinaemia
-QT prolongation
-hypotension
-hepatotoxicity
-hyperglycaemia
-weight gain

A

hepatotoxicity

84
Q

what monitoring is required with antipsychotics?

A

-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
Q

what is the MHRA alert for haloperidol?

A

risk of cardiac and neurological effects when used in elderly patients for delirium

86
Q

what is the MHRA alert for antipsychotics?

A

monitoring blood concentrations for toxicity

87
Q

what is the MHRA alert for clozapine?

A

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
Q

which two antipsychotics can be affected by smoking? and how?

A

clozapine and olanzapine - smoking decreases levels requiring increase increase in dose

Tobacco Can Avoid Overdose
Theophylline
Clozapine
Olanzapine
Aminophylline

89
Q

when administering antipsychotics in an emergency, which route should be used?

A

IM - smaller dose than oral

90
Q

What are the severe side effects of clozapine? and how do you manage these?

A

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
Q

what indication is clozapine licensed for?

A

resistant schizophrenia

(must have tried 2 or more drugs for at least 6-8 weeks)

92
Q

If more than 2 doses of clozapine have been missed, what should be done?

A

should be reinitiated

93
Q

which is the only antipsychotic not associated with prolactinaemia?

A

aripiprazole

94
Q

what is the treatment for neuroleptic malignant syndrome?

A

bromocriptine or dantrolene

95
Q

what motor symptoms are associated with PD?

A

hypokinesia, bradykinesia, rigidity, tremor, postural instability

96
Q

what non-motor symptoms are associated with PD?

A

dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing difficulties, weight loss

97
Q

In PD patients whose motor symptoms are affecting their quality of life, what should they be offered?

A

Co-careldopa (levodopa & carbidopa)
Co-beneldopa (levodopa & benserazide)

98
Q

In PD patients whose motor symptoms do not affect their quality of life, what should they be offered?

A

Levodopa
Non ergot Dopamine agonists (pramipexole, ropinirole, rotigotine)
MAOB inhibitors (rasagline, selegline)

99
Q

In PD patients whose symptoms are not well controlled despite optimal therapy with levodopa, what can be added?

A

Non ergot Dopamine agonists
MAOB inhibitors
COMT inhibitors (entacapone, opicapone, tolcapone)
Ergot dopamine agonists (bromocriptine, cabergoline, pergolide) - only if non-ergot ineffective

100
Q

what drug can be added on in patients with advanced PD?

A

apomorphine (intermittent injections or CSCI)

101
Q

when initiating a patient on apomorphine, what additional drug is recommedned?

A

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
Q

What are the mechanism of action of COMT inhibitors, and how do they help in PD?

A

they prevent the peripheral breakdown of levodopa, allowing more to reach the brain - useful for end of dose motor fluctuations

103
Q

entacapone may colour your urine what colour?

A

reddish/ brown

104
Q

what is the caution for tolcapone?

A

fatal hepatotoxcity

105
Q

what is the brand name of co-careldopa?

A

sinemet

106
Q

what is the brand name of co-beneldopa?

A

madopar

107
Q

what is the benefit of using the combination of co-beneldopa and co-careldopa?

A

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
Q

what are the side effects of co-careldopa and co-beneldopa?

A

impulse control (to a less extent than dopamine agonists)
excessive sleepiness/ sudden onset of sleep
motor complications (dyskinesia)

109
Q

why are non ergot dopamine agonists preferred over ergot derived?

A

ergot dopamine agonists have a high risk of fibrotic reactions:
-pulmonary (dyspnoea, persistent cough)
-retroperitoneal (abdo pain and tenderness)
-pericardial (cardiac failure)

110
Q

what are the side effects of dopamine agonists?

A

impulse control (gambling, hypersexuality, binge eating)
excessive sleepiness and sudden onset of sleep
psychotic symptoms (hallucinations, delusions)
hypotension reaction in first few days

111
Q

what is the advice surrounding application of the rotigotine patch?

A

patches should be removed for 24 hours and new patch applied to different area (avoid the same are for 14 days)

112
Q

what is the mechanism of action of MAOB inhibitors?

A

inhibit the enzyme responsible for the breakdown of dopamine

113
Q

MAOB inhibitors have a risk of hypertensive crisis when combined with which other medications?

A

-OTC decongestants (pseudoephedrine, xylometazoline …)
-Medications which increase BP (adrenaline …)

114
Q

in patients with PD who develop muscle cramps, what medication can b used?

A

quinine

115
Q

in patients with PD who develop excessive saliva/ drooling, what medication can be used?

A

glycopyrronium bromide

116
Q

in patients with PD who develop postural hypotension, what medication can be used?

A

midodrine

117
Q

what is the anti-emetic of choice in PD, and which should be avoided?

A

domperidone

Metoclopramide should be avoided

118
Q

what is the anti-emetic of choice in pregnancy?

A

promtheazine (short-term antihistamine)

118
Q

what is the anti-emetic of choice in pregnancy?

A

promethazine (short-term antihistamine)

if symptoms do not settle after 24-48 hours - specialist

** only treat if severe

119
Q

what are the risk factors for developing post-operative N&V?

A

female, younger, non-smoker, hx of postop N&V, opioid use

120
Q

what are the anti-emetics of choice for post-op N&V

A

two anti-emetics with different MoA:

ondansetron/ dexamethasone AND
cyclizine

121
Q

what is the anti-emetic of choice for motion sickness?

A

hyoscine hydrobromide

122
Q

what is the age restriction and max duration of metoclopramide?

A

> 18 years and max 5 days duration

123
Q

what is the age restriction and max duration of domperidone?

A

> 12 years and max 7 days duration

124
Q

what are the three different types of insomnia and how do you treat these?

A

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
Q

what is the max duration of use of Z drugs for insomnia?

A

4 weeks

(tolerance develops in 3-14 days of continuous use)

126
Q

which anti-epileptics have long half lives and can be given once daily?

A

phenytoin
lamotrigine
phenobarbital

127
Q

What is the three MHRA alerts for antiepileptics?

A

-risk of suicidal thoughts and behaviour
-switching between different brands
-antiepileptic drugs and pregnancy

128
Q

what 4 drugs are category 1 antiepileptics?

A

carbamazepine, phenobarbital, phenytoin, primdone

129
Q

patients who experience their first unprovoked epileptic seizure are not allowed to drive for how long?

A

6 months

130
Q

patients with established epilepsy are able to drive if they are seizure free for what length of time?

A

1 year

131
Q

epileptic patients who have a dose change, or withdrawal of their medication, should not drive for how long?

A

6 months

132
Q

which two antiepileptics are safer in pregnancy?

A

lamotrigine and levetiracetam

133
Q

which antiepileptics are unsafe in pregnancy?

A

valproate, carbamazepine, phenobarbital, topiramate (cleft palate)

134
Q

what is the treatment choice for tonic-clonic seizures?

A

1st valproate
2nd lamotrigine/ levetiracetam

135
Q

what is the treatment choice for absence seizures?

A

1st ethosuximide
2nd valproate

136
Q

what is the treatment choice for myoclonic seizures?

A

1st valproate
alternative - levetiracetam

137
Q

which anti-epileptics should not be used in myoclonic seizures?

A

carbamazepine, phenytoin

138
Q

what is the treatment choice for atonic/ tonic seizures?

A

1st valproate
alternative - lamotrigine

139
Q

what is the treatment choice for focal seizures?

A

1st levetiracetam and lamotrigine
alternative - oxcarbazepine, zonisamide, levetiracetam

140
Q

what advice should be given to epileptic patients who are pregnant?

A

-risk of harm from seizure outweighs risk of medication
-folic acid in first trimester
-vit K at birth - reduces risk of neonatal haemorrhage

141
Q

which anti-epileptics are associated with SJS?

A

lamotrigine

142
Q

which anti-epileptics are associated with hyponatraemia?

A

carbamazepine

143
Q

which anti-epileptics are associated with eye disorder?

A

topiramate (glaucoma)

144
Q

which anti-epileptics are associated with respiratory depression?

A

gabapentin and pregabalin

145
Q

which anti-epileptics are associated with blood dyscrasias?

A

carbamazepine, valproate, ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide

146
Q

what is the MHRA alert for gabapentin and pregabalin?

A

risk of severe respiratory depression

147
Q

what is the MHRA alert specific to phenytoin?

A

risk of death and sever harm with injectable phenytoin

148
Q

what is the MHRA alert specific to pregabalin?

A

risk of abuse and dependency

149
Q

what type of seizures is phenytoin indicated in? and which is it contraindicated in?

A

indicated for focal, generalised tonic-clonic

exacerbates absence and myoclonic

150
Q

what is the therapeutic range or phenytoin?

A

10-20mg/L

151
Q

what is phenytoin bound to?

A

highly protein bound, bound to albumin

152
Q

what is the conversion between phenytoin sodium and phenytoin base?

A

100mg phenytoin sodium = 92mg phenytoin base

153
Q

what are the signs and symptoms of phenytoin toxicity?

A

slurred speech
nystagmus
ataxia
confusion
hyperglycaemia
double vision

154
Q

what are the side effects of phenytoin?

A

coarsening of facial features
blood dyscrasias
skin reactions (SJS increased risk if asian)
low vitamin D
hepatotoxicity

155
Q

what type of seizures is carbamazepine indicated in? and which is it contraindicated in?

A

indicated for focal and generalised tonic-clonic

exacerbates atonic, clonic, myoclonic

156
Q

what is the therapeutic range of carbamazepine?

A

4-12 mg/L

measure after 1-2 weeks

157
Q

what are the signs and symptoms of carbamazapine toxicity?

A

hyponatraemia
ataxia
nystagmus
drowsiness
blurred vision
arrhythmias
GI disturbance

158
Q

what should you monitor for carbamazepine?

A

FBC, LFTs, renal profile

159
Q

during status epilepticus, if a seizure last longer than 5 minutes, what can be used as treatment?

A

IV lorazepam
buccal midazolam
rectal diazepam (if in community)

2nd dose can be given after 5-10 minutes if no improvement

160
Q

what is the definition of chronic pain?

A

pain occurring for longer than 12 weeks

161
Q

what is the licensed age for codeine?

A

> 12 years

contraindicated in patients under 18 who have had their tonsils removed

162
Q

in patients receiving regular strong opioids, what should be the strength of the breakthrough pain relief?

A

1/6th - 1/10th total daily dose

163
Q

what is first line for an acute migraine attack?

A

simple analgesic

164
Q

what is second line for an acute migraine attack?

A

5HT1 agonist (sumatriptan)

(can be repeated after 2 hours but only if shown response to first dose)

165
Q

what can be used as prophylaxis of migraine?

A

propranolol
amitriptyline
valproate

166
Q

which drugs can be used for opioid dependence?

A
  • methadone
    -buprenorphine
167
Q

if the patient misses more than 4 doses of their opioid maintenance therapy, what should you do?

A

refer

168
Q

what drug should be used to weaken symptoms of alcohol withdrawal?

A

long acting BZD:
chlordiazepoxide
diazepam

169
Q

what drug should be used for delirium tremens in alcohol withdrawal?

A

lorazepam

170
Q

what drugs can be used to prevent the risk of alcohol dependence relapse?

A

acamprosate or naltrexone

171
Q

what should be given to patients at risk of developing wernicke’s encephalopathy?

A

oral thiamine (B1)

172
Q

what drug treatments are options for aiding smoking cessation?

A

varenicline, bupropion, NRT

173
Q

Which antiepileptics have the highest presence in breastfeeding?

A

ethosuximide, primidone, lamotrigine, zonisamide

Pharmacy (20 decks)

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