CNS Flashcards
(156 cards)
1
Q
Focal seizure treatment
A
First line - lamotrigine/ levetiracetam
Second line - Carbamazepi, oxcarbazepine, zonisamide
2
Q
Generalised tonic clonic treatment
A
First line - Sodium valproate
Second line - lamotrigine/ levetiracetam
3
Q
Absence seizure treatment’s
A
First line - Ethosuximide
Second line - sodium valproate
4
Q
Absence seizure with other
A
First line - sodium valproate
Second line - lamotrigine/ levetiracetam
5
Q
Myoclonic treatment
A
Sodium valproate
Second line- levetiracetam
6
Q
Atonic seizure treatment
A
First line - sodium valproate
Second line - lamotrigine
7
Q
Tonic seizure treatment
A
First line - sodium valproate
Second line - lamotrigine
8
Q
Treatment of status epilepticus
A
- IV lorazepam (if resuss available/ buccaneers midazolam/ rectal diazepam
- Second dose if seizure not stopped within 5-10 mins
- Levetiracetam/ phenytoin/ sodium valproate
- Try another of the 3
- Phenobarbital / general anaesthetic if no response still
9
Q
Category 1 Antiepileptics
A
Carbamazepine, phenytoin, phenobarbital, primidone
Maintain brands
10
Q
Category 2 Antiepileptic drugs
A
Clobazam, clonazepam, lamotrigine, oxcarbazepine, perampanel, topiramate, rufinamide, valproate, zonisamide
Use clinical judgement for brands
11
Q
Category 3 Antiepileptic drugs
A
Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin
12
Q
Carbamazepine, phenytoin, sodium valproate drug interactions
A
- Hepatotoxicity - Amiodarone, itraconazole, macrolides, alcohol
- CYP enzyme - INDUCERS; Phenytoin, phenobarbital, carbamazepine/ INHIBITORS sodium valproate
- Lower seizure threshold - tramadol, theophylline, quinolones
CARBAMAZEPINE & hyponatraemic - ssri, diuretics
PHENYTOIN &Antifolates - methotrexate, trimethoprim
13
Q
Carbamazepine, phenytoin, valproate side effects
A
Depression, suicide, hepatotoxic, hypersensitivity, blood dyscrasia, vit D deficiency (bone pain)
CARBAMAZEPINE: oedema, hyponatraemia
Phenytoin: coarsen appearance, face hair
Sodium valproate: teratogenic ! Pancreatitis
14
Q
Antiepileptics likely to cause hypersensitivity
A
Category 1 & lamotrigine
15
Q
Antiepileptics likely to cause skin rash
A
Lamotrigine ( Steven Johnson’s syndrome )
16
Q
Antiepileptics likely to cause blood dyscrasia (C.VET.PLZ)
A
Carbamazepine, valproate , ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide
17
Q
Antiepileptics likely to cause eye disorders
A
Topiramate ( secondary glaucoma)
Vigabatrin (reduced field)
18
Q
Antiepileptics likely to cause encephalopathy
A
Vigabatrin
19
Q
Antiepileptics likely to cause respiratory depression
A
Gabapentin, pregabalin
20
Q
Therapeutic range of carbamazepine
A
4-12mg/L
21
Q
Signs of carbamazepine toxicity (HANDBAG)
A
Hyponatraemia, Ataxia, nystagmus, drowsiness, blurred vision, GI disturbance
22
Q
Phenytoin therapeutic range
A
10-12mg/L
23
Q
Signs of phenytoin toxicity (SNACHD)
A
Slurred speech,Nystagmus, ataxia, confusion, hyperglycaemia, double vision
24
Q
Driving after unprovoked/ single seizure
A
Notify DVLA, leave 6 months
25
Driving after established epilepsy
1yr/ pattern of seizures established over 1 yr with no impact on consciousness
26
Driving after Antiepileptics med change/ withdrawal
At least 6 months after dose change
If seizure occurs; license revoked for 1yr, reinstate after y months if treatment resumed and no further seizures
27
Antiepileptics high presence in breast milk (PELZ)
Primidone, ethosuximide, lamotrigine, zonisamide
28
Antiepileptics with risk of drowsiness in breast milk (PPB)
Phenobarbital, primidone, benzodiazepines
29
Antiepileptics with breast milk withdrawal effects if sudden stop (PPBL)
Phenobarbital, primidone, benzodiazepines, lamotrigine
30
Bipolar acute treatment
Benzodiazepines/ Antipsychotics ( quetiapine, olanzapine, risperidone)
Add ons - lithium/ sodium valproate
31
Managing mania/ hypomania in bipolar
1. Stop antidepressant & start antipsychotic (olanzapine, risperidone, quetiapine)
2. Try alternative antipsychotic
3. Lithium
32
Managing depression in bipolar
1. Psycho intervention
Mod - severe ; Fluoxetine & olanzapine, quetiapine, lamotrigine
33
Managing bipolar disorder long term
1. Lithium
2. Antipsychotic
34
Lithium therapeutic range
0.4-1mmol/L (0.8-1mmol/L acute)
35
Frequency of lithium monitoring
12 hours after dose, weekly till stable for first year then 6 monthly
36
Signs of lithium toxicity (REVNG)
Renal impairment/incontinence, extra pyramid tremors, visual disturbance (blurred), nervous system (confusion/restless), gi disorders (diarrhoea, vomit)
SICK & TREMOR
37
Lithium side effects
Thyroid disorders, nephrotoxicity, rhabdomyolysis, Qt prolongation, benign intracranial hypotension
38
Lithium interactions
Hyponatraemia (increase risk of toxicity ) - diuretics
Salt imbalance
Serotonin syndrome - ssri, tca
Extrapyramidal side effects - metoclopramide! Haloperidol
Qt prolongation - tramadol, theophylline
Re ally cleared drugs (increase toxicity)
Reduce seizure threshold
Hypokalaemia
39
Treatment of mild-mod dementia
Acetycholinesterase inhibitors; donepezil, rivastigmine, galantamine
40
Treatment of mod- severe dementia
Memantine
41
Treatment of aggravation in dementia
Benzodiazepines/ antipsychotic
42
Side effects of increased acetylcholine (DUMBBELS)
Diarrhoea, urinary incontinence, muscle weakness, bradycardia, bronchospasm, emesis, lacrimation, salivating
43
Treatment for Parkinson’s if motor symptoms decrease QOL
Levodopa + carbidopa/benserazide
44
Treatment for Parkinson’s if motor symptoms don’t effect QOL
Levodopa, non-ergot DA receptor, MAO-B Inhibitors
45
Action of carbidopa or benserazide
Prevent breakdown of levodopa before crossing BBB
46
Side effects of levodopa
Impulse disorders, sudden onset of sleep (treat with modalafil), red urine
47
Non- ergot derived DA receptor
Pramipexole, ropinirole, rotigotine
48
Non ergot da receptor side effects
Impulse disorders, sudden onset of sleep, hypotension
49
MAO-B Inhibitors
, selegiline, rasagiline
50
MAO-I interactions
Phenylephrine (hypertensive crisis)
Tyramine rich foods
51
Parkinson’s progression despite optimum levodopa
ADD non-ergot da receptor, mao b inhibitor, COMT inhibitors
52
COMT inhibitor side effects
Entacapone - red urine
Tolcapone - hepatotoxic
Increase sympathomimetic side effects- increased cvd
53
Nocturnal akinesia treatment
1. Levodopa/ da receptor
2. Rotigotine
54
Parkinson’s symptoms not fully controlled by adjunct non ergot
Ergot derived - bromocriptine, cabergoline
55
First gen (phenothiazines) antipsychotic GROUP 1
PROMAZINES; MOST sedation, MODERATE antimuscarinic, extra pyramid
Chlorpromazine, levopromazine, promazine
56
First gen group 2 phenothiazine antipsychotic (cyazine)
Pericyazine
MODERATE sedation LEAST extra pyramid
57
First gen group 3 phenothiazines antipsychotic (azines)
MOST extra pyramid, MODERATE sedation
Fluphenazine, prochlorperazine, trifluperazine
58
First gen butyrophenone antipsychotic (PERIDOLS)
Benperidol, haloperidol
SIMILAR TO GROUP 3- HIGH extra pyramid, MODERATE sedation
59
First gen thioxanthenes antipsychotic (PENTIXOL)
Flupentixol, zuclopenthiol
Moderate sedation - antimuscarinic AND extra pyramid
60
First gen other antipsychotic
Primozide, sulpride
Reduced sedation, antimuscarinic AND extra pyramidal
61
Antipsychotic monitoring weight
At start, weekly for first 6 weeks! At 12 weeks, 1 yr then annual
62
Antipsychotic blood glucose monitoring frequency
At start, as wks, 1 yr then annual
63
Antipsychotic BP monitoring
Start, at 12wks, 1 yr, annual
64
When to use clozapine
Resistant schizophrenia.
Only when 2+ antipsychotic used inc 1 second gen 6-8wks each
65
Clozapine monitoring
Leukocytes and differential blood count
Weekly for 18 weeks, fortnightly till 1 yr then monthly
66
Clozapine side effects
Myocarditis + cardiomyopathy - report + stop on tachycardia
Agranulocytoses and neutropenia - monitor
Gi - resport + stop in constipation
67
How many missed clozapine doses does it take to refer to specialist and retitrate
2+
68
Treatment of acute anxiety
Benzodiazepines - shortest course, lowest dose
69
Treatment of chronic anxiety
Ssri
Propranolol - alleviate physical symptoms
70
Long acting benzodiazepines
Diazepam, alprazolam, chlordiazepoxide,
Higher hangover effect
Also used in sleep maintenance
71
Short acting benzodiazepines
Lorazepam, oxazepam
Preferred in elderly and hepatic impairment
Higher risk of withdrawal symptoms (2-4 wks)
Little-no hangover effect
Also used for sleep onset
72
Benzodiazepines side effects
Paradoxical - aggression, hostility, talkative, anxious, excited
73
Treatment of benzodiazepine overdose
Flumazenil
74
Benzodiazepines with legal driving limit
Clonazepam, oxazepam, lorazepam, diazepam, flunitrazepam, temazepam
75
Benzodiazepines withdrawal effects
Anxiety, sweating, weight loss, tremors, loss of appetite
76
Benzodiazepines withdrawal treatment
1. Convert all to ON diazepam
2.Reduce by 1-2mg (1/10th of large dose) every 2-4wks
3. Reduce 0.5mg towards end
77
Treatment option for mild depression
CBT
78
Treatment of mod- severe depression
1. SSRI
2. increase dose/ change SSRI/ mirtazapine, MAO-I (specialist)/ TCA/ venlafaxine
3. Second line doesn’t work - add another class/ lithium/ antipsychotic
4. Electroconvulsive for severe refractory
79
SSRI side effects
GI disturbance
Appetite/ weight gain
Sexual dysfunction
Risk of bleed
Insomnia ( take in morning)
QT prolongation (citalopram/ escitalopram)
80
SSRI Interactions
CYP enzyme inhibitors - (grapefruit) increase plasma con
CYP enzyme inducers - reduce effectiveness
Drugs inducing risk of bleed
Hyponatraemia
Serotonin syndrome
81
Sedating TCA better for agitated or anxious
Amitriptyline, clomipramine, dosulepin, trazadone
82
Less sedating TCA
Imipramine, nortriptyline, lofepramine
83
TCA side effects (CASHH)
Cardiac events
Antimuscarinic
Seizures
Hypotension
Hallucinations
84
TCA Interactions
CYP inhibitors- grapefruit, reduce effectiveness
CYP inducers -reduce effectiveness
QT prolongation - amiodarone, Sotolol, quinolones
Antimuscarinic drugs
Anti hypertension
85
MAO-I interactions
Hepatotoxic - phenelzine, isocarboxazid
Hypertensive crisis -ephedrine
Tyramine rich foods
Tranylcypromine
Clomipramine
86
How long till antidepressants can be started after MAOI
2wks, 3wks clomipramine /imipramine
87
How long between MAOI
2 wks, 0 moclobemide
88
How long after TCA/ related to start MAOI
1-2wks / 3wks in clomipramine/imipramine
89
How long after SSRI to start MAOI
1wk , 5wks in fluoxetine
90
Cause of transient insomnia
Noise, shift work, jet lag
91
Treatment of transient insomnia
Rapidly eliminating hypnotic (1/2 doses)
92
Z hypnotics dependence period
3-14days
93
Z hypnotic dose restrictions
Intermittent doses, max 4 wks treatment
94
Z drug side effects
Drowsiness, dependence and paradoxical side effects
95
ADHD treatment regimen 5yrs+
1. Methylphenidate
2. If 6 wk trial at max dose doesn’t reduce symptoms - lisdexamfetamine/ dexamfetamine if lis not tolerable
3. Atomoxetine/ guanfacin if neither tolerated
96
Methylphenidate side effects
Cardiac - high blood, tachycardia, arrhythmia
CNS - behaviours change, drowsiness, sleep disorders
Decreased appetite, growth retardation, weight loss
97
Methylphenidate monitoring factors
Pulse, BP, psychiatric symptoms, appetite, weight, height
98
Methylphenidate monitoring frequency
At initiation then 6 monthly
99
Lisdexamphetamine OD symptoms
Wakefulness, excessive activity, paranoia, hallucinations, hypertension
Followed by - exhaustion, convulsions, hyperthermia, coma
100
Alcohol dependence withdrawal setting
Mild - usually don’t need assisted withdrawal
Mod - community unless high risk of seizure/delirium
Severe - inpatient withdrawal
101
Alcohol dependence first line treatment
CBT or acamprosate/ naltrexone
102
Alcohol dependence second line treatment
Disulfram
103
Treatment of alcohol withdrawal symptoms
Long acting benzodiazepines (chlordiazepoxide/diazepam)
Alternative - carbamazepine/ clomethiazole
104
Treatment of alcohol withdrawal delirium
Lorazepam
105
Treatment of wernicke’s encephalopathy
Thiamine (vit b1)
106
Nicotine replacement therapy
Patches - use 16hr in pregnancy and nightmares
AND
Short term reliever
107
Varenicline contraindications
Epilepsy, CVD, psychiatric illness
108
Bupropion contraindications
Avoid in psychiatric illness, seizures, eating disorders, serotonin syndrome
109
When to use Naloxone
Pts at high risk of opioid overdose
110
Length of initial supervised consumption in substance dependence and when to start
3 months, restarting after break, dose increase
111
Which treatment for patients continuing elicit drug use
Methadone
112
Methadone initial dose
10-30mg - tolerance not known = 10-20mg
113
Switching between buprenorphine and methadoone
Methadone to buprenorphine - reduce gradual then start buprenorphine after start of withdrawal symptoms
Buprenorphine to methadone - start 24hrs after last dose
114
Migraine lifestyle advise
Maintain hydration, sleep, exercise
Avoid chocolate and wine
Relax after stress
Headache diary to identify triggers
115
Acute migraine treatment
Aspirin, ibuprofen, 5HT1 agonist
116
Treatment of migraine with aura
Triptan (at start of headache not aura)
117
When to repeat Triptan dose
Repeat after 2hrs if first dose gives some response but not adequate
118
Second line migraine treatment
Soluble paracetamol
119
Antiemetics in migraine
Metoclopramide/ prochlorperazine
120
First line migraine prophylaxis
Propranolol - Metoprolol/nadalol if CI
121
Second line migraine prophylaxis
Amitriptyline - less sedating TCA if not tolerated
122
Third line migraine prophylaxis
Sodium valproate, pizotfen, Botox - under specialist
123
Acute treatment for cluster headaches
SC sumaptriptan (nasal suma/zolmi if unavailable)
124
Prophylaxis of cluster headaches
Verapamil, lithium, prednisone, ergotamine
125
Tigeminal neuralgia symptoms
Severe facial pain, electric shock like in jaw/teeth/gums
126
Tigemenial neuralgia treatment
Carbamazepine
127
Treatment of tension type headache
Paracetamol / ibuprofen
128
Nausea and vomiting treatment in preganancy
Promethazine if needed but avoid where possible
129
Nausea and vomiting in post op treatment
5HT3 receptor antagonist - Ondansetron OR dexamethasone
130
Treatment of pre op nausea and vomiting
Lorazepam
131
Motion sickness treatment
Hyoscine hydrobromide
132
Nausea and vomiting palliative treatment
Haloperidol / levomepromazine
133
Treatment for Nausea and vomiting in Parkinson’s disease
Domperidone - doesn’t cross BBB
134
Minimum age for domperidone
12yrs
135
Maximum treatment length for domperidone
7 days
136
Minimum weight for domperidone treatment
35kg
137
Side effects of metoclopramide
Extra pyramidal - avoid in Parkinson’s
138
Minimum age of metoclopramide
18yrs
139
Maximum treatment length of metoclopramide
5 days
140
Treatment of mild pain
Non-opiates - paracetamol, NSAIDs, aspirin
141
Treatment of Mild-moderate pain
Weak opioids - codeine, dihydrocodeine
Moderate - Tramadol
142
Tramadol side effects
Low seizure threshold, serotonin syndrome, increased risk of bleeding , psychiatric disorders
143
Treatment of moderate to severe pain
Strong opiates - morphine, oxycodone, methadone, buprenorphine, fentanyl
144
Minimum age of codeine
12 yrs, 18yrs if tonsils removed
145
Who should avoid codeine
Ultra metabolisers
Breastfeeding
146
Opiate side effects
Dry mouth, constipation, CNS depression, nausea and vomiting, hypotension, miosis (pupil constriction)
147
Risks of long term use of opiates
Hypogonadism, adrenal insufficiency, hyperalgesia
148
Opioid overdose treatment
Naloxone
149
When to avoid opiates
Paralytic ileus, respiratory disease, head injury
150
Opioid patch use
Avoid exposure to heat
Apply to dry and hairless area
Rotate site
151
Treatment of neuropathic pain
TCA - Amitriptyline, nortriptyline
Antiepileptics - Gabapentin/ pregabalin
Opiates - Tramadol, morphine, oxycodone,
Topical - lidocaine, capsaicin
152
Treatment of spasticity in multiple sclerosis
Baclofen, diazepam, tizanidine, dantrolene
153
Treatment of relapse in multiple sclerosis
Methylprednisolone
154
Treatment of oscillopsia in multiple sclerosis
Gabapentin
155
Treatment for mood in multiple sclerosis
Amitriptyline
156
treatment for fatigue in multiple sclerosis
Amanda dine/fampridine
