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Pradeepa's notes > CNS > Flashcards

CNS Flashcards

1
Q

1st line tx of focal seizures

A

lamotrigine/levetiracetam

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2
Q

2nd line tx of focal seizures

A

carbamazepine, oxcarbazepine, zonisamide

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3
Q

different types of generalised seizures

A

-tonic-clonic
-absence
-absence + other
-myoclonic
-atonic
-tonic

-for child-bearing age = 2nd line tx

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4
Q

tx of tonic-clonic seziures

A

1)sodium valproate
2)lamotrigine, levetiracetam

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5
Q

tx of absense seizures

A

1)ethosuximide
2)sodium valporate

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6
Q

tx of absence + other type of seizures

A

1)sodium valproate
2) lamotrigine/ levetiracetam

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7
Q

myoclinic seziures tx

A

1)sodium valproate
2) levetriacetam

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8
Q

atonic seziures tx

A

1)sodium valproate
2)lamotrigine

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9
Q

tonic seizures tx

A

1)sodium valproate
2)lamotrigine

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10
Q

what is status epilepticus

A

-seizures that last longer than 5 mins
-need to provide resuscitation and immediate emergency tx
1)pt = individualised emergency manage plan
2)pt = x “”

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11
Q

status epilepticus tx

A

-Standard tx
1) longer than 5 mins
->IV lorazepam (resuscitation if available)
->buccal midazolam/rectal diazepam (community)
–>give second dose if seizure x stop within 5-10mins of 1st dose
2)if seizure x respond after 2x benzodiazepine doses
-> levetiracetam, phenytoin, sodium valproate
3) if seizure fails to respond try another 2nd line if still x respond
->phenobarbital/general anaesthesia

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12
Q

category 1 of anti-epileptic drugs

A

-specific brands only
-carbamazepine, phenobarbital, phenytoin, primidone

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13
Q

category 2 of anti-epileptic drugs

A
  • maintain specific brands based on clinical judgement + pt factors
    -clobazam, clonazepam, lamotrigine, oxcarbazepine, perampanes, rufinamide, topiramate, valproate, zonisamide
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14
Q

category 3 of anti-epileptic drugs

A

-unnecessary to ensure - specific brands
- brivaracetam, ethosuximide, gabapentin, laxosamide, levetiracrtam, pregabalin, tigabine, vigabatrin

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15
Q

anti-epileptic drug interactions
(carbamazepine, phenytoin, sodium valproate)

A

-hepatotoxicity - amiodarone, itraconazole, macrolides, alcohol
-CYP enzymes - inducers (phenytoin, phenobarbital + carbamazepine) inhibitors (sodium valproate)
-drugs lower seizure threshold - tramadol, theophylline, quinolones, —>carbamazepine = hyponatraemic drugs (SSRI + diuretics)
->phenytoin = anti-folate(methotrex + trimethoprim)

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16
Q

carbamazepine, phenytoin, sodium valproate s/e

A

-carbamazepine, phenytoin, sodium valproate
->suicide, depression, hepatotoxicity, hypersensitivity, blood dyscrasia, vit D deficiency
-carbamazepine; hyponatraemia, odema
-phenytoin; coarsening appearance, facial hair
-sodium valproate; pancreatitis, teratogenic

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17
Q

anti-epileptic drug s/e

A

-hypersensitivity - carbamazepine, phenobarbital, phenytoin, primidone, lamotrigine
-skin rash - lamotrigine (steven-johnson syndrome)
-blood dyscrasia - carbamazepine, valproate, ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide
-eye disorder - vigabatrin (reduce visual field) topiramate (secondary glaucoma)
-encephalopathy - vigabatrin
-respiratory depression - gabapentin + pregabalin

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18
Q

carbamazepine range + signs of toxicity

A

-therapeutic range- 4-12mg/l
-Hyponatraemia
-ataxia (poor muscle control)
-nystagmus (involuntary movement of eyes)
-drowsiness
-blurred vision
-arrythmias
-GI disturbances

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19
Q

phenytoin range + signs of toxicity

A

-therapeutic range - 10-20mg/l
-slurred speech
-nystagmus (involuntary mov of eyes)
-ataxia (poor muscle control)
-confusion
-hyperglycaemia
-double vision

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20
Q

epilepsy + driving

A

-stop driving + inform DVLA (fit)
-1st unprovoked/single isolated = 6MT
-established epilepsy = 1yr (or pattern of seizures established for 1yr with no impact on consciousness)
-medication change/withdrawal - x drive 6MT after last dose, seizure = occur license removed for 1yr, reinstated for after 6MT if tx resumed + no seizure occur

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21
Q

epilepsy + pregnancy

A

-risk of harm to mother + fetus from convulsive seizures outweighs risk of continued therapy
-folic acid given to reduce risk of neural tube defects in 1st trimester
-vit K inj adminstered - birth reduces neonatal haemorrhage
-most risk - sodium val -PPI
- topiramate - celft palate

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22
Q

what is bipolar disorder

A

extreme fluctuation between maniac phases (overactive + excitability) + depressive phases (reclusive + lethargic)

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23
Q

tx acute of bipolar disorder

A

-benzodiazepines
-antipyschotics (quetiapine, olanzapine/risperdone)
-> add lithium or sodium valproate

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24
Q

tx prophylaxis of bipolar disorder

A

-carbamazepine, sodium valproate or lithium

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25
Q

lithium range

A

-therapeutic range - 0.4-1mmol/l (acute episodes - 0.8-1)
-measure levels 12hr after each dose - weekly till stable then 3MT X 1YR * 6MT

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26
Q

lithium toxicity

A

-CUT-DVB
Renal impairment - incontinence
-extrapyramidase s/e - tremor
-visual disturbance - blurred vision
-nervous system disorder - confusion + restlessness
-diarrhoea + vomiting

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27
Q

lithium s/e

A

-QT2-BNR
thyroid disorder
-nephrotoxicity
-rhabdomyolysis
-QT prolongation
-benign intercranial hypertension
-1st trimester = teratogenic

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28
Q

lithium interactions

A

-hyponatraemia = high risk of toxicity - diuretics
-salt imbalance
-serotonin syndrome
-extrapyramidal s/e
-QT prolongation
-renally cleared drugs (high risk of toxicity
-dec seizure threshold
-hypokalmaeia

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29
Q

dementia?

A

alleviated by high amount of acetylcholine

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30
Q

tx of dementia mild to moderate

A

-acetylcholinesterase inhibitors
-donepezil = neuroleptic malignant syndrome
-rivastigmine - GI s/e - less in transdermal formulations
-galantamine -steven-johnsons syndrome

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31
Q

tx of dementia moderate to severe

A
  • memantine
    -aggravation tx with benzodiazepines or antipsychotics
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32
Q

s/e of dementia tx

A

-high acetylcholine = parasympathetic s/e
-stop tx + tx dehydration before reinitiating/amending dose
-diarrhoea
-urinary incontience
-muscle weakness
-bradycardia
-bronchospasm
-emetis
-lacrimation
-salivation

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33
Q

parkinsons?

A

alleviated levels of dopamine

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34
Q

pt = parkinsons whose motor symptoms reduce QoL tx

A

levodopa + carbidopa/berserazide

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35
Q

pt = parkinsons whose motor symptoms x affect QoL TX

A
  • levodopa
    -non-ergot derived dopamine receptor
    -monoamine-oxidase B inhibitors
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36
Q

what is added to levodopa in order to prevent breakdown of levodopa before it crosses into the brain

A

-carbidopa/benserazide is added
-impulsive disorders; pathological gambling, binge eating, hypersexuality
-sudden onset of sleep (tx modafinil) red urine

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37
Q

non-ergot derived dopamine-receptor -
pramipexole, ropinirole + rotigotine

A

-impulse disorders (higher than levodopa)
-sudden onset of sleep
-hypotension

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38
Q

-rasagiline or selegiline interactions

A

monoamine-oxidase B inhibitors
-causes hypertensivie crisis if given with phenyleprine
-interacts with tyramine rich foods
->mature cheese, salami, marmite, yeast, tofu

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39
Q

when is non-ergot dopamine receptor agonists, monoamine oxidase B inhibitors or COMT inhibitors added to levodopa

A

it is added to levodopa in pt who develops dyskinesia or motor fluctuations despite optimal levodopa therapy

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40
Q

entacapone and tolcapone

A

-COMT inhibitors
-entacapone - red-brown urine
- tolcapone - hepatotoxic
- inc sympathetic s/e in CVD events

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41
Q

when is ergot dervied dopamine receptor agonist added to levodopa

A
  • if symptoms x adequately controlled with non-ergot “”
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42
Q

ergot dervied receptor agonists -
bromocriptine, cabergoline

A
  • pulmonary reactions; report SoB, chest pain, cough
    -pericardial reactions; chest pain
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43
Q

withdrawal of medications

A

-if person = off-periods due to deterioation use MR preparations
-tx natural akinesia with levodopa or oral dopamine receptor agonists as 1st line + rotigotine - 2nd line
-tx hypertension = midodrine

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44
Q

psychosis + schizophrenia +ve symptoms

A

delusions, hallucinations, disorganisations

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45
Q

psychosis + schizophrenia -ve symptoms

A

social withdrawal, neglect, poor hygiene

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46
Q

antipsychotics 1st gen

A

phenothiazines
thioxanthenes
butyprohenones

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47
Q

antipsychotics 2nd gen

A

olanzapine
clozapine
risperidone
quetiapine
aripiprazole
ziprasidone
paliperidone
asenapine
lurasidone
iloperidone

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48
Q

antipsychotics how many groups of phenothiazines

A

group 1
group 2
group 3

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49
Q

1st gen phenzothiazines group 1

A

-chlorpromazine, levomepromazine, promazine
-most sedation, moderate antimuscarinic + EPSEs

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50
Q

1st gen phenzothiazines group 2

A

-pericyazine
-moderate sedation least EPSEs

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51
Q

1st gen phenzothiazines group 3

A

-fluphenazine, prochlorperazine, trifluoperazine
-moderate sedation high EPSEs

52
Q

benperidol + haloperidol

A

-1st gen butyrophenones
-moderate sedation high EPSEs

53
Q

flupentixol, zuclopentinixol

A
  • 1st gen thioxanthies
  • moderate sedation, antimuscarinic effects + EPSEs
54
Q

1st gen others

A

-pimozide + sulpride
-reduced sedation, antimuscarinic effects +EPSEs

55
Q

2nd gen antipsychotics

A

-amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone

56
Q

antipsychotics s/e

A

-extrapyramidal - group 3 phenothiazines + butyropheriones
- hyperprolactinaemia = less in aripiprazole
- sexual dysfunction = all
- cardiovascular - QT prolongation pimozide + haloperidol

57
Q

common antipyschotic s/e

A

-hypertension - clozapine + quetiapine
-hyperglycaemia - clozapine, risperidone, olanzapine, quetiapine
-weight gain; olanzapine + clozapine
-neuroleptic malignant syndrome stop tx and tx with bromocriptine (should resolve 5-7DY)

58
Q

antipyschotics monitoring

A

-weight; weekly for 6W12WK1YRyearly
-fasting blood glucose, hb2ac, blood lipid conc - @12WK1YRyearly
-ECG - before initiation
-blood pressure: @12WK1YR*yearly
-FBC, U+Es, LFT= @ start then yearly

59
Q

clozapine

A

-used in resistant schizo
-only when 2+ antipyschotics including one 2nd has been used for 6-8WK each
-IF MISSED MORE THAN 2 DOSES = SPECIALIST REINITIATION
-monitor levocyte + differentia blood counts
->weekly 18wk
->every 2 weeks for 1 yr
->monthly

60
Q

clozapine s/e

A

-myocarditis + cardiomyopathy - report + stop tachycardia
-agranulocytes + neutropenia - monitor leucocyte + different blood counts
-GI disturbances

61
Q

anxiety tx acute

A

benzodiazepines

62
Q

chronic anxiety tc

A

SSRI- sertaline, citalopram, escitalopram, fluoxetine, propanolol - alleviates physical symptoms only

63
Q

benzodiazepines

A

-can induce hepatic coma especially long-acting benzodiazepines tx with lowest dose for shortest time

64
Q

benzodiazepines short-acting

A

-lorazepam + oxazepam
-preferred in elderly + hepatic impairment
- greater risk of withdrawal symptoms (2-4wk)

65
Q

benzodiazepines long-acting

A

diazepam, alprazolam, chlordiazepoxide , hydrochloride, clobazam

66
Q

benzodiazepines paradioxial effects

A

-agression, hostility, talkative, anxious, excited

67
Q

benzodiazepines sedation

A

increased with sue of alcohol, CNS depressants or CYP enzyme inhibitors avoid concomitant use

68
Q

benzodiazepines driving

A

-avoid if drowsy
-legal driving limit = clonazepam, axaepam, lorazepam, diazepam, flunitrazepam + temazepam

69
Q

benzodiazepines overdose tx

A

flumazenil

70
Q

benzodiazepines withdrawal

A

-dependence; anxiety, sweating, weight loss, tremors, loss of appetite
1)convert all medciation to ON dose of diazepam
2) reduce by 1-2mg (1/10th of larger doses) every 2-4wk - only withdraw further if overcome withdrawal symp
3) reduce further 0.5mg near end

71
Q

depression

A

less serotonin, dopamine, norephedrine, atosynaptic cleft

72
Q

mild depression tx

A

-CBT

73
Q

moderate to severe depression tx

A

-antidepressants
-pt may feel worse in 1st 1-2WKs
-should be taken for 4WK (6wk elderly) before seen as ineffective
-take for 6MT after remission, 1yr elderly, 2yr - recurrent

74
Q

depression tx

A

-1st line = SSRI
- x work:
-> inc dose
-> change SSRI
-> mirtazepine
-> MAOI-I (specialist)
-> TCA or venlafaxine (severe)
- x work after changes then add another class - lithium or antipsychotics
-use electroconvulsive therapy = severe refractory depression

75
Q

SSRI s/e

A

-GI (D+V)
- appetite / weight gain
- sexual dysfunction
- risk of bleed
-insomnia (take in morning)
QT prolongation (escitalopram + citalopram)

76
Q

SSRI interactions

A

-CYP inhibitors - avoid grapefruit inc plasma conc
-CYP inducers lower effectivness
-drugs - QT prolongation = amiodarone, sotalol, quinolones
-drugs inc risk of bleed
-hyponatraemia = carbamazepine _ diuretics
-serotonin syndrome

77
Q

serotonin syndrome

A

-cognitive effects; headaches, agitation, hypomania, coma, confusion,
-autonomic; sweating, hyperthermia, nausea, diarrhoea
-neuromuscular exictation; myclonus, tremor, teeth grinding
-caused by
->SSRI, TCA, MAO-I
->triptans
->tramadol
->lithium

78
Q

TCA

A

-sedating - better for agitated + anxious pt
-> amitriptyline, clomipramine, dosulepim, trazadone
-less sedating = better for withdrawn ) apathetic pt
->imipramine, lofepramine, nortriptyline
-amitriptylline + dosulepin = dangerous overdose

79
Q

TCA s/e

A

-cardiac events
-anti-muscarnic
-seizures
-hypotension
-hallucinations

80
Q

TCA interactions

A

-cyp inhibitors (avoid grapefruit)
- cyp inducers ( reduce effectiveness)
-drugs = QT prolongation
-anti-muscarinic drugs
-anti-hypertensive drugs
-serotonin syndrome

81
Q

MAOI-I

A

-specialist use
-causes hepatotoxicity phenazine + isocarboxazid
-hypertensive crisis X pseudoephedrine
- avoid tryamine rich foods
-tranylcypromine + clomipramine = fatal

82
Q

MAOI washout period

A

-antidepressant = x start for 2wk after tx with MOAI (3wk for clomipramine or imipramine)
- x start MOAI until
-> 2wk after previous MOAI has been stopped (0WK for meclobemide)
->1-2wk after TCA or related has been stopped
-1wk after SSRI or related antidepressants x (5WK fluoxetine)

83
Q

transient insomnia

A

-external factors - noise, shift work, jet lag
-rapidly eliminated hypnotic = chosen _ only 1/2 doses given

84
Q

short term insomnia

A

-emotional problem or serious medical illness
-hypnotic useful x given for more than 3 wk (1wk ideal)

85
Q

chronic insomnia

A

-normally = anxiety, depression, alcohol/drug abuse
-underlying psychiatric compliant = tx

86
Q

benzodiapines insomnia long acting

A

nitrazepam, diazepam, flurazepam
-higher hangover effect following day
-used for sleep disturbances

87
Q

benzodiapines insomnia long acting

A

-loprazolam, lermetazepam, temazepam
-little or no hangover effect
-sleep onset
-high chance of withdrawal symptoms

88
Q

Z-hypnotics

A

-zolpidem + zopiclone
-high GABA - CNS depression
-dependency occurs within 3-14DY of use
-should be taken intermittently
-should be used for 4wk max
-benzo + z-drugs avoid in elderly due to falls + injury
-parodoxidal S/E
-drowsiness
dependence

89
Q

children 5+ ADHD

A

1) methylphenidate = 1st line
2) if 6wk trial at max dose x work then switch to lisdexamfetamine (dexamfetamine if x tolerate longer duration)
-if intolerant to both methyl + lisde - 3) atomxetine or guanfacine

90
Q

TX of adult ADHD

A

1)methylphendiate or lisdexamfetamine (dexamefatamine x tolerate)
2) atomextine ( causes QT prolongation, hepatotoxicity, suicidal ideation)
-MR prep = preferred - brand specific
-> pharmacokinetic profile, convivence increase adherence

91
Q

methylphendiate

A

-CNS stimulant
-inc BP, tachycardia + arrythmias
-behaviour/mood change, drowsiness + sleep disorders
-low appetite, growth retardation + weight loss
-monitor pulse, BP, psychiatric symp, appetite, weight + weight at initiation, following dose adjustments *6MT

92
Q

lisdexamfetamine + dexamfetamine

A

-similar S/E to methylphenidate
-overdose causes wakefulness, excessive activity, paranoia, hallucinations, hypertension followed by exhaustion, convulsions, hyperthermia, coma
-similar monitoring as methylphenidate

93
Q

alcohol dependence mild tx

A
  • no assistance needed
94
Q

alcohol dependence moderate tx

A
  • community tx unless at high risk of developing alcohol withdrawal seizures or delirium
95
Q

alcohol dependence severe tx

A

-undergo withdrawal in inpatient setting

96
Q

alcohol dependence tx

A
  • CBT or with acamprosate or naltrexone (alternate; disulfiram)
    -withdrawal symptoms; long-acting benzodiazepine = chlordiazepoxide or diazepam ( alternate; carbamazepine or clomethiazole)
    -delirium; lorazepam
  • wernick’s encephalopathy; thiamine (vit b12)
97
Q

nicotine dependence tx

A

-varenicline
-> avoid in epilepsy, cardiovascular disease + psychiatric illness
-bupropion
-> avoid in psychiatric illness, seizures, eating disorders
->causes serotonin syndrome
-NRT
->use as a patch 6HR if pregn/nightmares AND use short term reliever - lozenges, gum, sublingual tabs, inhalator, nasal spray or oral spray

98
Q

opioid dependance tx

A

-under qualified prescriber supervision
-prescribed on FP10MDA max 14DY supply
-three or more missed doses - specialist
-tx continue through pregn
-naloxone - prescribed if high risk of overdose
-buprenorphine
->less sedating than methadone
->milder withdrawal symp
-> lower risk of overdose
->substance (buprenorphine with naloxone) when risk of injecting
-methadone
-> causes QT prolongation
-> carefully titrated according to pt needs

99
Q

migraines

A

unilateral, pulsating, severe enough to affect daily activities, freq accompained by N+V, phtophobia + phonophobia

100
Q

migraines with aura

A

-precede most at onset of headache
-visual symp (zigzag, flickering lights, spots, lines)
-sensory symp (pins + needles, numbness)
-dsyphagsia

101
Q

migraines with aura lifestyle advice

A

-maintain hydration, sleep, exercise
-avoid choco + wine
-relax after stress
-headaches diary = useful triggers

102
Q

migraines with aura acute tx

A

-aspirin, ibuprofen, 5HTI-receptor agonist - sumatriptan
-asap when symp start
-with aura = triptan/start of headaches x aura
-triptan can be repeated 2hr (4hr-naratriptin) only if response to 1st dose x adequate
-soluble paracetamol if x favorable
-antiemetics - metoclopramide or prochlorperazine

103
Q

migraine prophylaxis

A

-1st line: propranolol (CI then metoprolol/nadolol)
-amitriptyline effective if sedating use less sedating TCA or not tolerated
-sodium valproate, pizotifen, botox = specialist

104
Q

cluster headache

A

-intense unilateral pain or around one eye
-acute; SC sumatriptan (nasal sumatriptan/zolmitriptan if unavailable)
-prophylaxis; verapamil, lithium, prednisolone or ergotamine tartate

105
Q

trigeminal neuralgia

A

severe facial pain = electrical shock in jaw, teeth or gums
tx- carbamazepine

106
Q

tension headache

A

-bilateral throbbing pain like tight band around head
-tx- paracetamol or ibuprofen

107
Q

N+V tx

A

antihistamines = cyclizine + promethazine or phenothiazines (prochlorperazines) are usual tx in prophylaxis or tx of N+V

108
Q

N+V tx pregn

A

avoid drug therapy use promethazine if needed

109
Q

N+V tx post-op

A

5HT3-receptor antagonist ondansetron or dexamethasone

110
Q

N+V tx pre-op

A

lorazepam

111
Q

N+V tx motion sickness

A

hyoscine hydrobromide

112
Q

N+V tx terminal illness

A

antipsychotics (haloperidol + levomepromazine)

113
Q

N+V tx parkinsons

A

domperidone

114
Q

domperidone

A

-x cross blood barrier brain so ideal in parkisons
-10mg TDS
-12YR+
-7DY only
-35kg+ can cause QT prolongation

115
Q

metoclopramide

A

-can cause extrapyramidal s/e = x parkinsons
-10mg TDS
-min 18yr
-5DY max use

116
Q

mild pain tx

A

-non-opiates paracetamol, ibuprofen, NSAID, aspirin

117
Q

mild to moderate pain tx

A

-weak opiates; codeine/dihydrocodiene
-moderate ; tramadol (less seizure threshold, serotonin syndrome, high risk of bleed, psychiatric disorders)

118
Q

moderate - severe pain tx

A

-strong opiates; morphine, oxycodone, methadone, buprenorphine, fentanyl

119
Q

codeine

A

-12yr+
-x children <18 - tonsils removed due to sleep apnea
- x pt - ultra rapid metaboliser (Afro-Caribbean) toxicity
- x breastfeeding

120
Q

opiate s/e

A

-act on mu-pathway causing
-dry mouth
-constipation
-CNS depression
-N+V
-hypotension
-miosis (pupil constriction)

121
Q

strong opiates

A

-prolonged use; hypogonadism, adrenal insufficiency, hyperglyesia
-overdose; use naloxene
-aovid in paralytic ileus, respiratory disease + head injury
-breakthroguh pain 1/6th to 1/10th total daily dose evety 2-4hr
-inc opiate doses by 1/2 to 1/3 each day
-dec doses to 1/2 to 1/3 when switching to x overdose
-oxycodone more potent than morphine = more appropriate in pt x consume large amounts due to nausea
-patches avoid exposure to heat, apply to dry, hairless skin + rotate area
-fentanyl; remove patch immediately if toxicity signs

122
Q

neuropathic pain tx

A

-TCA = amitriptyline, nortriptyline
-antiepileptics = gabapentin, pregabalin
-opiates = morphine/oxycodone
-topical localised = lidocaine/capsaicin

123
Q

main two types of focal seizures

A

-focal aware seizures
-focal impaired awareness seizures

124
Q

focal aware seizures

A

-general strange feeling hard to describe
-rising feel in stomach (ride feeling)
-deja vu
-unusual smell or taste
-tingling sensations in arms/legs
-sudden feeling or fear or joy
-twitching or stiffness in arm or hand
-these are = warning/aura to show another type of seizure on way

125
Q

focal impaired awareness seizures

A

-lose sense of awareness - won’t remember what happened after
-random bodily behaviour
->smacking lips
->rubbing hands
->random noises
->moving arms around
->picking at clothes
->fiddling with objects
->adopting an unusual posture
-> chewing or swallowing
-> wont be able to respond to anyone

Pradeepa's notes (12 decks)

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