CNS Flashcards
(151 cards)
1
Q
First line treatment of focal seizures
A
Lamotrigine or Levetiracetam
2 L’s
2
Q
Second line treatment of focal seizures
A
Carbamazepine
Oxcarbazepine
Zonisamide
COZ
3
Q
First line treatment of generalised seizures
Tonic-clonic, myoclonic, atonic, and tonic (not absence)
A
Sodium Valproate
4
Q
Second line treatment of generalised seizures
Tonic-clonic, myoclonic, atonic, and tonic (not absence)
A
Lamotrigine (tonic-clonic, atonic, tonic)
or Levetiracetam (tonic-clonic, myoclonic)
5
Q
First line treatment of absence seizures (when patient ONLY experiences absence seizures)
A
Ethosuximide
6
Q
Second line treatment of absence seizures (when patient ONLY experiences absence seizures)
A
Sodium Valproate
7
Q
First line treatment of absence seizures (in addition to other seizures)
A
Sodium Valproate
8
Q
Second line treatment of absence seizures (in addition to other seizures)
A
Lamotrigine/ Levetiracetam
9
Q
What are exceptions to seizure guidelines
A
If sodium valproate first line, use second line treatment.
Valproate is only to be initiated in men and women under 55 if 2 specialists independently document that there is no alternative.
10
Q
What is status epilepticus and how should it be handled?
A
Seizure lasting >5 mins.
Provide resuscitation and immediate emergency treatment:
1. IV lorazepam (if available) or if not buccal midazolam or rectal diazepam.
2. Give second dose after 5-10 minutes.
3. If seizure fails to respond, give one of Levetiracetam, Phenytoin, or Sodium valproate.
4. If seizure fails to respond again, give a different one of Levetiracetam, Phenytoin, or Sodium valproate.
5. If still not responding, give either phenobarbital or general anaesthesia.
11
Q
What are the 3 categories of anti-epileptic drugs?
A
Category 1: MUST maintain on same brand throughout treatment
Category 2: maintenance on brand based on clinical judgement
Category 3: not necessary to stay on same brand
12
Q
Which anti-epileptics are in category 1?
A
Carbamazepine, Phenobarbital. Phenytoin, Primidone
CPPP
13
Q
Which anti-epileptics are in category 2?
A
- Clobazam
- Clonazepam
- Lamotrigine
- Oxcarbazepine
- Perampanel
- Rufinamide
- Topimarate
- Valproate
- Zonisamide
14
Q
Which anti-epileptics are in category 3?
A
- Brivaracetam
- Ethosuximade
- Gabapentin
- Lacosamide
- Levetiracetam
- Pregabalin
- Tiagabine
- Vigabatrin
15
Q
Key anti-epileptic interactions
For carbamazepine, phenytoin, and valproate
A
- Hepatotoxics e.g., amiodarone, itraconazole, macrolides, alcohol.
- Drugs which lower seizure threshold e.g., tramadol, theophylline, quinolones.
- CYP substrates (inducers: phenobarbital, phenytoin, carbamazepine. Inhibitors: sodium valproate)
- (Carbamazepine only) hyponatraemic drugs e.g., SSRIs, diuretics
- (Phenytoin only) anti-folates e.g., MTX, trimethoprim
16
Q
Key anti-epileptic side effects
10
A
- Depression + suicide
- Hepatotoxicity
- Vit D deficiency - bone pain.
- Hypersensitivity (CPPP + Lamotrigine)
- Blood dyscrasia (Carbamazepine, valoroate, ethosuximide, topiramate, phenytoin, lamotrigine, zonisamide) C VET PLZ
- Hyponatraemia (carbamazepine)
- Oedema (carbamazepine)
- Coarsening appearance + facial hair (Phenytoin)
- Pancreatitis (sodium valproate)
- Respiratory depression (gabapentin, pregabalin)
- Encephalopathy (Vigabatrin)
- Vision disorders (Vigabatrin, Topirmate)
- Teratogenicity (Topiramate, Valproate)
17
Q
What is the therapeutic range of carbamazepine?
A
4-12mg/L
18
Q
What are the signs of carbamazepine toxicity?
A
HANDBAG
- Hyponatraemia
- Ataxia
- Nystagmus
- Drowsiness
- Blurred Vision
- Arrythmias
- GI distrurbances
19
Q
Phenytoin therapeutic range
A
10-20mg/L
20
Q
S
Signs of phenytoin toxicity
A
CHANDS
* Confusion
* Hyperglycemia
* Ataxia
* Nystagmus
* Slurred speech
Pheny sounds like funny –> chandler from friends
21
Q
Rules for driving with epilepsy
A
- When an epileptic seizure, stop driving immediately and inform DVLA.
Can restart driving: - 6 months after first unprovoked/single isolated seizure
- 1 year after last seizure in established epilepsy
- 6 months after last dose of regular medicine if withdrawing or switching. If seizure occurs, license revoked for a year. If regular treatment resumed and no further seizures occur, license can be reinstated after 6 months.
22
Q
Rules for epilepsy in pregnancy.
A
- Generally, risk of harm to mother and fetus from convulsive seizures outweighs risk of continued therapy.
- Ensure folic acid given in first trimester.
- Vitamin K administered at birth to minimise neonatal haemorrhage.
- DO NOT get pregnant on sodium valproate or topiramate (PPP).
23
Q
Rules for Pregnancy Prevention Programme.
A
- Use of these medicines (e.g., valproate, topiramate, tretinoin, thalidomide) are contraindicated unless the conditions of PPP are fulfilled.
- Pregnancy must be ruled out before treatment with a negative plasma pregnancy test.
- Patient must use either one “highly effective” contraception (e.g., IUD, implant, sterilisation) or 2 forms of contraception including barrier method.
- Regular pregnancy tests should be considered.
24
Q
Breastfeeding in epilepsy advice
A
- Encourage breast-feeding
- Primidone, Ethosuximide, Lamotrigin, and Zonisamide have high presence in milk - monitor baby.
- Risk of drowsiness in baby with Primidone, Phenobarbital, and Benzodiazepines.
- If mother suddenly stops breast-feeding, baby may experience withdrawal with phenobarbital, primidone, benzos, or lamotrigine, so wean slowly.
25
What is bipolar disorder?
Extreme fluctuation between manic phases (overactive, impulsive, excitable) and depressive phases (reclusive, lethargic)
26
How is an acute manic episode managed?
- benzodiazepines
- Antipsychotics - quetiapine, olanzapine, risperidone
- Add Lithium or valproate
27
How is bipolar disorder managed?
Mood stabilisers:
- Carbemazepine
- Sodium valproate
- Lithium
28
Lithium therapeutic range
0.4-1.0mmol/L
(or 0.8-1.0mmol/l in acute episodes)
29
How regularly should lithium levels be measured?
Weekly till levels stable.
Then 3 monthly for 1 year.
Then 6 monthly thereafter.
## Footnote
Levels taken 12 hours post-dose.
30
Signs of lithium toxicity
REVNG
- renal impairment
- EPSEs e.g., **tremors**
- Visual disturbances e.g., blurred
- Nervous system disorders e.g., confusion, restlessness
- GI disorders - diarrhoea and vomiting
## Footnote
Tremors are characteristic of lithium toxicity
31
Lithium side effects and monitoring
- Lithium levels
- Increased weight (BMI)
- Thyroid (hypo and hyper) & teratogenicv in 1st trimester
- Heart/ECG - QT prolongation
- Intercranial hypertension
- U &Es - renal excretion, nephrotoxic, can cause hyperparathyroidism, hypercalcaemia, and hypokalaemia. Hyponatraemia (associated toxicity).
- Muscle - rhabdomyolysis
32
Lithium Interactions
- Diuretics – reduce clearance leading to increase in lithium by 25-400% (mainly thiazide-like).
- - ACE inhibitors – decreased excretion leading increase levels and can precipitate renal failure
- NSAIDs – may increase lithium levels by 40-50%.
- - Dapagliflozin – decreased lithium levels due to increased renal excretion.
- Haloperidol – neurotoxicity.
- Carbamazepine – neurotoxicity.
- Antidepressants – CNS toxicity..
- Antiepileptics - Reduced sezure threshold
- Serotonin syndrome - SSRIs, st johns wort, sumatriptan.
- QT interval prolongation.
- Hypokalaemia
- Hyponatyraemic drugs e.g., SSRIs. diuretics - increased risk of toxicity.
33
First line treatment of mild-moderate dementia
Acetylcholinesterase inhibitors:
- Donepezil
- Rivastigmine
- Galantamine
| Dr G
34
First line treatment of moderate-severe dementia.
Memantine
35
Treatment of dementia-associated agitation
Antipsychotics
NOT to be used in Parkinsons dementia
36
Side effects of acetylcholinesterase inhibitors
Increased acetylcholine results in parasympathetic side effects (DUMBBELS)
- Diarrhoea
- Urinary incontinenance
- Muscle weakness
- Bradycardia
- Bronchospasms
- Emesis
- Lacrimation (tears)
- Salivation
Donepezil - NMS
Rivastigmine - GI AEs
Galantamine - Stevens-Johnson Syndrome
37
Choice of Parkinson's medication.
* QOL NOT affected by motor symptoms: Levodopa, non-ergot dopamine agonist, or MAO-B inhibitors.
* QOL affected by motor symptoms: co-careldopa or co-beneldopa
* Motor fluctations and dyskinesia despite optimal levodopa therapy: COMT inhibitors
38
How do decarboxylase inhibitors work?
When co-administered with levodopa, benserazide and carbidopa prevent the premature conversion of levodopa to dopamine before it crosses the BBB and reaches its active site.
Alone, only 10% may cross BBB and 1% will reach active site.
39
Common side effects of levodopa
- Nausea and vomiting
- Impulse disorders e.g., binge eating, pathological gambling, hypersexuality.
- Narcolepsy (sudden onset of sleep) - treat with modafinil
- Red urine
40
What are the non-ergot-derived dopamine receptor agonists?
Pramipexole
Ropinirole
Rotigotine
41
Common side effects of dopamine agonists.
- Nausea and vomiting
- Impulse disorders e.g., binge eating, pathological gambling, hypersexuality. (MORE likely than levodopa)
- Narcolepsy (sudden onset of sleep) - treat with modafinil
- Hypotension
42
Examples of MAO-B inhibitors
Selegiline
Rasagiline
Safinamide
| Parkinson's is SRS
43
MAO-B inhibitor interactions
Phenylephrine (e.g., in sudafed) - can cause hypertensive crisis.
DOESN'T interact with tyramine rich foods - this is MAO-A inhibitors only.
44
COMT inhibitors examples
Entacapone
Tolcapone
45
What is the role of COMT inhibitors?
Inhibits catechol-O-methyltransferase, an enzyme which breaks down levodopa (and other catecholamines). This increases the bioavailability of levodopa and reduces off periods.
46
# S
Side effects of COMT inhibitors
Increase sympathetic side effects (e.g., tachycardia, arrythmias, hypertension, constipation) which can increase risk of CVD events.
Entacapone: red-brown urine
Tolcapone: hepatotoxic
47
Why are ergot-derived dopamine agonists not commonly used?
Bromocriptine and cabergoline are associated with:
- pulmonary reactions e.g., SOB, chest pain, cough,
- Pericardial reactions e.g., chest pain
However, if a non-ergot dopamine agonist is insufficient, they can be used.
48
Long-acting benzodiazepines examples
- Alprazolam
- Clobazam
- Diazepam
- Chlordiazepoxide
| ACDC - going for a long time
49
Short-acting benzodiazepines
-Oxazepam
Midazolam
- Lorazepam
| OML
50
Which benzodiazepines have a legal driving limit?
COLD FT
Clonazepam
Oxazepam
Lorazepam
Diazepam
Flunitrazepam
Temazepam
51
Benzodiazepine overdose treatment/antidote
Flumazenil
52
What are paradoxical effects of bezodiazepines?
Aggression
Hostility
Anxious
Manic
53
Symptoms of benzodiazepines withdrawal
SWAT
- Sweating
- Anxiety
- Weight and appetite loss
- Tremors
54
How to treat benzodiazepine withdrawal
1. Convert all benzos to once nightly dose of diazepam.
2. Reduce by 1-2mg every 2-4 weeks, or slower if experiencing symptoms.
3. Reduce by 0.5mg towards the end until completely weaned off.
55
Pathophysiology of depression
A reduction in serotonin, dopamine, and noradrenaline in the synaptic cleft.
56
What is first line treatment of mild depression?
CBT
57
What should be kept in mind when starting anti-depressants?
Worsened symptoms for 1-2 weeks.
Takes a few weeks to work. Should be taken for 4 weeks (6 weeks in elderly) before deemed ineffective.
58
How long should anti-depressants be taken after remission?
Normally: 6 months
Elderly: 1 year
Recurrent: 2 years
59
Treatment pathway for moderate-severe depression?
1. An SSRI
2. Increase dose
3. Try different SSRI
4. Mirtazapine
5. TCA or Venlafaxine (SNRI)
6. MAOi (specialist)
7. + in another class, lithium, or antipsychotic
8. ECT in severe refractory depression
60
What is first choice SSRI in adults and why?
Sertraline - generally safest in patients with cardiac events.
61
First choice SSRI for depression in children?
Fluoxetine
62
SSRI side effects
D&V
Increased appetite/weight gain
Sexual dysfunction
Bleed risk
Insomnia - take OM
QT prolongation - mostly with citalopram and escitalopram
63
SSRI interactions
- CYP inhibitors e.g., grapefruit, clarithromycin, anti-fungals
- CYP inducers e.g., smoking, anti-epileptics
- QT prolongation e.g., amiodarone, sotalol, quinolones
- Bleed risk e.g., NSAIDs, DOACs, warfarin
- Hyponatraemic drugs e.g., carbamazepine, diuretics
- Serotonin syndrome e.g., ondansetron, tramadol, St Johns wort
64
Symptoms of serotonin syndrome
- Cognitive effects: headache, agitation, hypomania, coma, confusion
- Autonomic effects: sweating, hyperthermia, nausea, diarrhoea
- Neuromuscular excitation - myoclonus, tremor, teeth grinding
65
Drugs which can cause serotonin syndome
- Anti-depressants: SSRIs, SNRIs, TCAs, MAO-Is
- Triptans: sumatriptan, almotriptan, zolmitriptan
- Some opioids: Tramadol, fentanyl, methadone
- Lithium
- Linezolid
- St John's wort
- Ondansetron
66
What are the 2 types of TCAs?
Sedating: amitriptyline, clomipramine, dosulepin, Trazodone
Less sedating: Nortiptyline, imipramine, lofepramine
67
Which 2 TCAs are least recommended for depression?
Amitriptyline and Dosulepin due to their danger in overdose.
68
TCA side effects
CASHH
Cardiac events
Anti-muscarinics
Seizures
Hypotension
Hallucinations
+ danger in overdose
69
TCA interactions
- CYP inhibitors e.g., grapefruit, clarithromycin, anti-fungals
- CYP inducers e.g., smoking, anti-epileptics
- QT prolongation e.g., amiodarone, sotalol, quinolones
- Anti-hypertensives e.g., CCBs, beta-blockers, ACEis
- Anti-muscarinic drugs (high ACB score) e.g., solifenacin, atropine
- Serotonin syndrome e.g., ondansetron, tramadol, St Johns wort
70
Which MAO-inhibitos can cause hepatotoxicity?
Phenelzine
Isocarboxazid
71
Which drugs should patients avoid tyramine rich foods?
MAO-A inhibitors
72
Name 3 key MAO inhibitor interactions
MAO-A inhibitors + tyrosine-rich foods
Pseudoephedrine - can cause hypertnesive crisis
Tranylcypromine (MAOi) + Clompipramine (TCA) = fatal toxicity (separate by 14 days)
73
How long should you wait to start another antidepressant after stopping a MAO-I?
14 days
74
How long should you wait to start an MAO-I after stopping a TCA?
1-2 weeks
75
How long should you wait to start an MAO-I after stopping an SSRI?
1 week
EXCEPT fluoxetine (5 weeks)
76
What are the 3 types of insomnia?
* Transient insomnia - caused by external factors (e.g., noise, shift work, jet lag).
* Short-term insomnia - caused by emotional or medical illness.
* Chronic insomnia - caused by an underlying psychiatric issue such as anxiety, depression, or alcohol/drug abuse.
77
How should transient insomnia be treated?
OTC meds
or
raoidly eliminated hyponotic (supply only 1-2 doses)
78
Treatment of short-term insomnia
Hypnotic used for ideally upto 1 week, but max 3 weeks.
79
Chronic insomia treatment
Treatment of underlying cause
80
When are long and short acting benzos used in sleep disorders?
Long acting e.g., diazepam are used for sleep maintenance. They can cause a hangover effect the following day.
Short acting e.g., temazepam are used for sleep onset. They have little or no hangover effect but there is higher chance of withdrawal.
81
How do Z-drugs work?
Increase GABA levels which causes CNS depression as it is an inhibitory neurotransmitter.
82
Guidance for use of zopiclone and zolpidem for sleep.
Should be taken intermittently and for a maximum of 4 weeks.
83
How long can it take to become dependent on Z-drugs?
3-14 days
84
What are the 2 types of hypnotics used for insomnia?
Z-drugs (zopiclone and zolpidem)
Benzodiazepines
85
Treatment of ADHD minimum age.
5
86
ADHD treatment pathway in children
1. Methylphenidate
2. Methylphenidate max dose for at least 6 weeks
3. Switch to Lisdexamfetamine (or dexamfetamine if not tolerated due to long duration of side effects)
4. Atomoxetine or Guanfacine
87
ADHD treatment pathway in adults
1. Methylphenidate or Lisdexamfetamine (or dexamfetamine if not tolerated due to long duration of side effects)
2. Atomoxetine
88
Atomoxetine side effects
QT prolongation
Hepatotoxicity
Suicidal ideation
89
How should ADHD meds be prescribed?
Generally, modified-release is preferred due to their pharmacokinetic profile, cpnvenience, and improved adherence.
All modified-release preperations should be prescribed as BRAND ONLY.
90
ADHD medication side effects
| Methylphenidate, Lisdexamfetamine, Dexamfetamine
CNS stimulant so causes hypertension, tachycardia, and arrithmias. Plus:
* Behaviour/mood change
* Drowsiness
* Sleep disorders
* Decerased appetite and weight loss
* Growth retardation (in children)
91
ADHD meds monitoring requirements
| Methylphenidate, Lisdexamfetamine, Dexamfetamine
At iniation, after dose adjustments, then 6 monthly:
* Pulse
* BP
* Appetite
* Weight
* Height (in children)
* Psychiatric symptoms
92
Symptoms of Lisdexamfetamine and Dexamfetamine overdose
Initially: alertness, excessive activity, paranoia, hallucinations, hypertension.
Followed by: exhausation, convulsions, hyperthermia, coma.
| Up then crash
93
Setting for alcohol withdrawal
* Mild: usually do not require assisted-withdrawal.
* Moderate: treated in a community setting unless high risk of delirium tremons
* Severe: Undergo withdrawal in an inpatient setting.
94
Treatment of alcohol dependence
CBT and/or Acamprosate of Naltrexone. Disulfram-type reaction drugs can be used
Withdrawal symptoms treated with long-acting benzodiazepines e.g., chlordiazepoxide. Alternatively carbamazepine or clomethiazole
95
Smoking cessation treatment
1. Patch + short-term reliever e.g., loxenges, gum, SL tabs, inhalator, nasal sprays
2. Oral anti-craving: Bupropion or Varenicline
96
How does varenicline work in smoking cessation?
Nicotine receptor blocker which prevents pt feeling effect of smoking
97
How does bupropion work for smoking cessation?
Noradrenaline-dopamine reuptake inhibitor - decreases dopamine uptake involved in reqard pathways associated with nicotine.
98
When should Varenicline be avoided?
* Epilepsy
* CVD
* Psychiatrc illness
99
When should bupropion be avoided?
* Psychiatric illness
* Seizures
* Eating disorders
* Concurrent use of drugs associated with serotonin syndrome.
100
When should a 16-hour nicotine patch be used?
In pregnancy or in patients who experience nightmares
101
What prescription should opioid dependence treatment be prescribed on?
FP10MDA
102
Can methadone/buprenorphine be used during pregnancy?
Yes - higher risk if using illicit drugs
103
How many missed doses of methadone/buprenorphine require referral?
3+
Risk of reduced tolerance - will need retitrating.
104
What may be prescribed concurrently with methadone/buprenorphine?
Naloxone if pt is high risk of dependence
105
Pros and cons of buprenoprhine vs methadone
Buprenorphine
* Less sedating and has milder withdrawal symptoms
* Fewer drug interactions
* Less risk of overdose (if using other drugs) and can come formulated with naloxone (Suboxone)
* HOWEVER - tends to retain fewer patients in treatment than methadone
Methadone
* Higher risk of QT prolongation
* Can be carefully titrated to the nearest ml dpeneding on patient's needs
106
Why might a sugar-containing form of methadone be prescribed over sugar-free?
If patient is at risk of injecting, a sugar-containing formulation will be more painful and irritating to the injection site, so will deter the patient.
107
Symptoms of migraine
* Unilateral, pulsating headache
* Nausea and vomiting
* Photophobia
* Phonophobia
108
What is an aura
Symptoms preceding onset of migraone headache:
* Visual e.g., zigzag/flickering lights, spots, lines
* Sensory e.g., pins and needles, numbness
109
Migraine lifestyle advice
* Maintain hydration, sleep and exercise
* Avoid chocolate and wine
* Relax after stress
* Use a headache diary to identify potential triggers
110
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Acute treatment of migraine
Ideally NSAID such as aspirin or ibuprofen, or a 5HT-1 agonist (i.e., a triptan).
Soluble paracetamol may be taken if above is contraindicated - soluble = faster onset.
Anti-emetics if requred: metcolopramide or prochlorperazine.
111
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Triptan counselling points
Take at start of headache, not at start of aura.
Repeat after 2h ONLY if there has been a response to the first dose but is not sufficient. Do not take another if there was no response to first dose - will not help.
112
Migraine prophylaxis pathway
1. Propanolol (or metoprolol or nadalol) or Topiramate
2. Amitryptyline (or less sedating TCA e.g. notriptyline)
3. Specialist: sodium valproate, pizotifen, botox.
113
Symptoms of cluster headache
Intense unilateral pain in or around one eye
114
Acute treatment of cluster headaches
* Sumatriptan (SC or nasal)
* Nasal Zolmitriptan
115
When are triptans contraindicated?
Uncontrolled hypertension
116
How do 5HT-1 agonists / triptans work?
Constrict blood vessels
117
Symptoms of trigeminal neuralgia
Severe facial pain which feels like an elecric shock through the jaw, teeth, or gums
118
Prophylaxis of cluster headaches
* Verapamil
* Lithium
* Prednisolone
* Ergotamine tartate (rare)
119
Treatment of trigeminal neuralgia
Carbamazepine
120
Symptoms of tension headache
Bilateral throbbing pain - like a tight band around the head.
121
Treatment of tension headache
OTC painkillers e.g., paracetamol or ibuprofen
122
Criteria for migraine preventative treatment
* Significant impact on QOL and daily function
* Acute treatments are contraindicated or ineffective
* They are risk of a medication overuse headache due to frequent use of acute drugs.
123
Prevention of menstrual-related migraines
Frovatriptan or Zolmitriptan on the days before migraine is expected or from 2 days before until 3 days after bleeding starts.
124
Anti-emetics in pregnancy
Generally avoid using drug-treatment, but if necessary:
* Promethazine
* Chlorpromazine
* Metoclopramide
* Prochlorperazine
* Ondansetron
* Doxylamine with pyridoxine.
125
Anti-emetics for post-op N&V
Ondansetron or Dexamethasone
126
Treatment for for pre-operative/anticaptory N&V
Lorazepam - deal with anxiety beforehand
127
Treatment of motion sickness
Hyoscine hydrobromide
128
Treatment of N&V in terminal illness
Haloperidol and Levomepromazine
129
Treatment of N&V in patients with Parkinsons
Domperidone
130
Minimum age for metoclopramide
18
131
Minimum age for domperidone
12
Note minimum weight is 35kg
132
Maximum duration of domperidone
7 days
133
Maximum duration of metoclopramide
5 days
134
When is metoclopramide contraindicated?
Parkinson's disease - crosses BBB and acts as dopamine agonist so can cause EPSEs.
135
Examples of weak opiates
Codeine
Dihydrocodeine
136
Example of moderate opiates
Tramadol
137
Examples of strong opiates
Morphine
Oxycodone
Methadone
Bupreorphine
Fentanyl
138
Tramadol adverse effects
* Lowers seizure threshold
* Risk of serotonin syndrome
* Increased risk of bleed
* Pyschiatric disorders
139
Morphine maximum daily dose
No maximum - dependent on weight and tolerance
140
When should codeine be avoided?
* Under 12s
* Under 18 who have had tonsils removed - sleep apnoea
* Ultra-rapid metabolisers (usually Afro-Caribbean) - toxicity
* Breastfeeding - present in breastmilk -
141
Opiate side effects
Act on the mu-pathway, causing:
* Dry mouth
* Constipation
* Nausea and vomiting
* CNS depression
* Pupil constriction (miosis)
* Hypotension
142
Adverse effects of long-term therapy with strong opiates
* Hypogonadism
* Adrenal insufficiency
* Hyperalgesia (due to tolerance)
143
How should breakthrough pain relief be prescribed?
1/6th - 1/10th of total daily dose every 2-4h, maximum 6 doses daily.
144
When should strong opiates be avoided?
* Respiratory disease
* Paralytic ileus (decreases peristalsis)
* Head injury
145
How should opioids be increased/decreased?
1/2 - 1/3 each day
146
When might oxycodone be used over morphine
* Renal impairment - oxycodone only partially renally excreted.
* N&V or swallowing issues- more potent so less quantity needed
147
Treatment of neuropathic pain
First line:
* Amitriptyline
* Duloxetine
* Pregabalin
* Gabapentin
148
When might opiates be used in neuropathic pain?
Tramadol may be used short-term while waiting for specialist referral.
149
What is multiple sclerosis?
Chronic autoimmune disease which causes demyelinating of the central nervous system resulting in:
* Spasticity
* Fatigue
* Mood alteration
* Oscillopsia
150
How is baclofen initiated and why?
Start low and increase slowly to avoid major side effects such as sedation and hypotonia (reduced muscle tone).
151
What is baclofen?
Anti-spasmodic which acts as a GABA-B agonist in order to inhibit neuronal excitability and neurotransmitter release in the CNS.
