CNS Flashcards
(313 cards)
1
Q
Treating (attenuating) alcohol withdrawal symptoms
A
Long acting benzodiazepine (e.g. Chlordiazepoxide/diazepam), carbamazepine or clomethiazole (inpatient only)
2
Q
How to treat alcohol withdrawal seizures
A
Fast acting benzodiazepine e.g. Lorazepam
3
Q
What is delirium tremens characterised by
A
Agitation, confusion, paranoia and visual and auditory hallucinations
4
Q
Treating alcohol dependence
A
Psychological intervention, acamprosate, oral naltrexone
5
Q
Wernickes treatment
A
Parenteral and then oral thiamine
6
Q
Dental anaesthetics
A
Lidocaine, mepivicaine (can be used without adrenalin in patients with heat problems), prilocaine
7
Q
Why are neuromuscular blocking drugs used
A
To provide relaxation and prevent reflex muscle movements (facilitating tracheal intubation)
8
Q
Propofol characteristics
A
Rapid recovery, less hangover effect
9
Q
Nitrous oxide use
A
Maintaining anaesthesia for analgesia
10
Q
NO and air pressure
A
Increased pressure in closed spaces so dangerous in patients with no pneumothorax, intracranial air, underwater dive, intraocular injection
11
Q
Treating musculoskeletal pain
A
Non-opioid, paracetamol, aspirin, NSAIDS
12
Q
Visceral pain treatment
A
opioids
13
Q
Pain medication to avoid in sickle cell crisis
A
Pethidine, as accumulation of a neurotoxic metabolite can precipitate seizures
14
Q
Oral mucosal pain
A
Benzydamine hydrochloride mouthwash or spray until cause dealt with
15
Q
General dental pain relief treatment
A
NSAIDS (paracetamol for antipyretic effect)
16
Q
Dental pain and opioids
A
Opioids are relatively ineffective
17
Q
Dysmenorrhoea treatment
A
Paracetamol, NSAID, antiemetic if needed, antispasmodics (alverine citrate)
18
Q
Naproxen Dysmenorrhoea/MSK Pain regimen
A
Initially 500 mg, then 250 mg every 6–8 hours as required, maximum dose after the first day 1.25 g daily.
19
Q
Aspirin pain indications
A
Headache, transient musculoskeletal pain, dysmenorrhoea, and pyrexia
20
Q
Pros and cons of enteric aspirin
A
Slow onset, so unsuitable for single dose analgesic use but prolonged action may be useful for night pain, less gastric irritation
21
Q
Nefopam indication and regumen
A
Initially 60 mg(30mg in elderly) 3 times a day, adjusted according to response; usual dose 30–90 mg 3 times a day. Moderate pain.
22
Q
Issue with caffeine in analgesic preparations
A
Withdrawal may result in headache
23
Q
Morphine contraindications
A
raised intracranial pressure, respiratory depression, head injury,
24
Q
Morphine side effects
A
appetite decreased; asthenic conditions; gastrointestinal discomfort; insomnia; neuromuscular dysfunction
25
Buprenorphine unique attribute
Opioid agonist and antagonist, naloxone only partially reverses
26
Buprenorphine relative to morphine
Longer duration, sublingually 6-8 hours
27
Why is diamorphine used in palliative care
Less nausea and hypotension, greater solubility so smaller volumes required in emaciated patients
28
Methadone vs morphine
Less sedating, longer duration
29
Oxycodone vs morphine
Similar so used second line
30
Pethidine vs morphine
Short acting, less constipating, less potent, used in labour but morphine preferred for obstetric pain
31
Tapentadol MOA (vs morphine)
Inhibits noradrenaline and opioid agonist, has less NV, constipation
32
Tramadol MOA
Opioid and serotonergic and adrenergic pathways inhibitor
33
When is codeine used
When paracetamol and ibuprofen are ineffective
34
Codeine vs dihydrocodeine
Similar, high doses of dihydro may provide more pain relief but more nausea and vomiting too
35
Meptazinol indication
Moderate to severe pain
36
When are antidepressants used
Moderate to severe depression (mild depression but history of moderate/severe depression)
37
Different Antidepressant classes
MAOI, SSRI, TCA
38
Why/when is electroconvulsive treatment required in severe depression
There may be a 2 week interval before antidepressant action takes place, the delay may be hazardous or intolerable
39
What may occur during first few weeks of treatment
Increased potential for agitation, anxiety and suicidal ideation
40
SSRI vs other antidepressants
Safer in overdose than others, sertraline can be used in unstable angina/recent MI, are less sedating and have less antimuscarinic and cardiotoxic effects than TCA
41
TCA vs other antidepressants
Similar efficacy to SSRIs, more side effects leading to discontinuation and toxicity in overdose is problematic
42
Antidepressant monitoring at initiation frequency
Review every 1-2 weeks at the start
43
How long should antidepressants be used for before considering a switch
At least 4 weeks (6 weeks in elderly) ( if there is a partial response continue for further 2-4 weeks)
44
What to do for patients following remission
Antidepressant treatment continued at same dose for at least 6 months (12 in elderly or receiving treatment for GAD)
45
What to do for patients with history of recurrent depression
Maintenance treatment for at least 2 years
46
Common side effect amongst antidepressants
Hyponatraemia (particularly elderly potentially due to secretion of antidiuretic hormone)
47
What class if antidepressants is hyponatraemia most common in
SSRIs
48
When to consider hyponatremia in those taking antidepressants
Drowsiness, confusion, convulsions
49
Serotonin syndrome cause
excessive central and peripheral serotonergic activity
50
When does serotonin syndrome occur
Hours/days following initiation/dose escalation/overdose of serotonergic drug or replacement without a washout particularly when the first drug is irreversible MOAI/long half life
51
Symptoms of serotonin syndrome
Neuromuscular hyperactivity, autonomic dysfunction, altered mental state
52
Altered mental state
Agitation, confusion, mania
53
Autonomic dysfunction
Tachycardia, blood pressure, hyperthermia, diaphoresis, shivering, diarrhoea
54
Neuromuscular hyperactivity
Tremor, hyperreflexia, clonus, myoclonus, rigidity
55
Treating serotonin syndrome
Withdrawal of serotonergic medication, supportive care and specialist advice
56
What to do if failure to respond to SSRI
Increase SSRI dose or switch to different SSRI/mirtazapine
57
Second line antidepressant treatment
Mirtazapine, lofepramine, moclobemide, reboxetine
58
Mirtazapine class
presynaptic alpha2-adrenoreceptor antagonist which increases central noradrenergic and serotonergic neurotransmission.
59
Venlafaxine class
A serotonin and noradrenaline re-uptake inhibitor.
60
Lofepramine class
TCA
61
Moclobemide class
MAOi
62
When is venlafaxine used
Severe depression
63
What to do if failure to respond to second line antidepressant
Different antidepressant class used, augmenting agent e.g. Lithium, aripiprazole, olanzapine, quetiapine, risperidone (all except lithium unlicensed) or electroconvulsive therapy
64
Managing acute anxiety
Benzodiazepine or buspirone
65
Chronic anxiety length
More than 4 weeks
66
Treating chronic anxiety
Antidepressant
67
How to overcome antidepressant not working initially when treating anxiety
Benzodiazepine given
68
How to treat GAD
Psychological treatment before initiating an antidepressant
69
Antidepressants used in anxiety
SSRI e.g. Escitalopram, paroxetine, sertraline (unlicensed), SNRI e.g. Duloxetine and venlafaxine , pregabalin if both classes fail
70
Treating Panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder a
SSRIs first line. Second line: clomipramine (ocd/panic) moclobemide (sad) imipamine (panic)
71
TCA MOA
Block the re-uptake of both serotonin and noradrenaline, although to different extents
72
TCAs with sedative properties
Amitriptyline hydrochloride, clomipramine hydrochloride, dosulepin hydrochloride, doxepin, mianserin hydrochloride, trazodone hydrochloride, and trimipramine.
73
TCAs with less sedative properties
Imipramine hydrochloride, lofepramine, and nortriptyline.
74
What TCA type to use for agitated anxious patients
Sedative
75
What percent of patients does TCA not work on
10-20% so use sufficiently high dose
76
MAOi and interaction avoidance
Other antidepressant should not be started 2 weeks after treatment with MAOis (3 weeks for clomipramine or imipramine)
77
When can you start MAOi after another MAOi
at least 2 weeks after a previous MAOI has been stopped (then started at a reduced dose)
78
When can you start MAOi after TCA
at least 7–14 days after a tricyclic or related antidepressant (3 weeks in the case of clomipramine or imipramine) stopped
79
When can you start MAOi after SSRI
at least a week after an SSRI or related antidepressant (at least 5 weeks in the case of fluoxetine) has been stopped
80
Who responds best to MAOi
Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features
81
TCA and the elderly
STOPP in those with dementia, narrow angle glaucoma, cardiac abnormalities, urinary retention history, prostatim, and if first ;ine
82
Isocarboxazid and phenelzine risk
Hepatotoxicity (all MAOi)
83
MAOi monitoring
Blood pressure
84
MAOi counselling points
Patients should be advised to eat only fresh foods and avoid food that is suspected of being stale or ‘going off’. This is especially important with meat, fish, poultry or offal; game should be avoided.
Avoid alcohol
85
Tyramine-rich food
Mature cheese, salami, pickled herring, Bovril®, Oxo®, Marmite® or any similar meat or yeast extract or fermented soya bean extract, and some beers, lagers or wines
86
Foods containing dopa
Broad bean pods
87
Contributions to hypertensive symptoms when on MAOi
Tyramine rich foods and dopa containing foods
88
ADHD characteristics
Hyperactivity, impulsivity, inattention leading to social/educational/occupational difficulties
89
Non-drug ADHD treatment
Balanced diet, good nutrition, regular exercise, environmental modifications, lighting , noise, reducing distraction, shorter periods of focus with movement breaks
90
ADHD first line
Lisdexamfetamine, methylphenidate 6-week trial
91
When is dexamfetamine used in ADHD
If the patient has a beneficial response from lisdexamfetamine but can't tolerate longer duration
92
Why is MR ADHD treatment used
Pharmacokinetic profile, convenience, improved adherence, reduced risk of drug diversion, no need to take at work
93
Drugs that shouldn't be generally stopped before surgery
Antiepileptics, antiparkinsonian drugs, antipsychotics, anxiolytics, bronchodilators, cardiovascular drugs, glaucoma, immunosuppreants, thyroid/antithyroid
94
When should lithium be stopped before a surgery
24 hours before if major, can continue if minor
95
ACE/ARB and surgery
Severe hypotension after anaesthesia so discontinue 24 hours before surgery
96
Anaesthesia and corticosteroids
Anaethesists should be informed of corticosteroid use including inhalers because blood pressure may drop if there is no corticosteroid during anaesthesia
97
When should potassium sparing diuretics be stopped before surgery
The morning due to hyperkalaemia arising from renal impairment
98
Substitution therapy missed doses repercussions
Missing 3 days = reduce dose due to overdose risk, missing 5 days = restart, especially buprenorphine
99
Why is buprenorphine preferred to methadone
Less sedating, interactions, easier dose reductions, lower overdose risk, alternate days at higher doses, shorter drug-free period before naltrexone induction to prevent relapse, titrate more rapidly
100
When does buprenorphine precipitated withdrawal occur
Other opioid agonists in circulation , occurs 1-3 hours within first buprenorphine dose
101
What is given when symptoms of precipitated withdrawal are severe
Lofexidine adjunctive therapy
102
Pregnancy and opioid substitution
Should be done as benefits outweigh risks, maintenance regimen, withdrawal not recommended in first and third trimester
103
Symptomatic opioid withdrawal treatment
Loperamide for diarrhoea, mebeverine for stomach cramps, metoclopramide for nausea, short acting benzo for insomnia
104
Opioid antagonist
Naloxone
105
Naltrexone action
Precipitates withdrawal symptoms , prevents relapse
106
Sedation for dental procedures
Diazepam and temazepam, effective anxiolytics, conscious sedation
107
Treating early stages of agitation/behavioural disturbance (mania)
Benzodiazepine
108
Antipsychotics used to treat acute mania/hypomania
Olanzapine 5-10mg, quetiapine, risperidone 2mg
109
Long term management of bipolar
Olanzapine in those that responded to it in a manic episode(monotherapy or with lithium/valproate)
110
Preventing bipolar
Lithium, (olanzapine, quetiapine) Carbamazepine if unresponsive to alternatives and have 4/more episodes a year), valproate also used
111
Use of valproate in bipolar
Treatment of manic episodes and prophylaxis of bipolar can add or switch to lithium/olanzaine if ineffective, can increase valproate dose during episodes of mania
112
Role of lithium in bipolar
Prophylaxis and treatment of mania, hypomania and depression in bipolar disorder (manic-depressive disorder), and in the prophylaxis and treatment of recurrent unipolar depression. Can be used concomitantly with antidepressants.
113
How long does it take for full lithium prophylactic effect
6-12 month window
114
Treating aggressive or self harming behaviour
Lithium
115
Positive symptoms
Thought disorder, hallucinations, and delusions
116
Negative symptoms
Apathy , social withdrawal
117
Antipsychotic and positive/negative
Relieve positive symptoms and prevent relapse
118
Negative symptoms treatment
Second gen antipsychotic
119
1st generation antipsychotic MOA
Blocks dopamine D2 brain receptors, not selective
120
Group 1 phenothiazine drugs and characteristics
Chlorpromazine, levomepromazine, and promazine,
| pronounced sedative effects and moderate antimuscarinic and extrapyramidal side-effects
121
Group 2 phenothiazine drugs and characteristics
Least EPS, moderate sedative effects, pericyazine, more antimuscarinic
122
Group 3 phenothiazine drugs and characteristics
Most EPS, few sedative, few antimuscarinic, fluphenazine decanoate, perphenazine, prochlorperazine, and trifluoperazine,
123
What group of phenothiazine's do butyrophenones e.g. Haloperidol clinically resemble
3
124
Second gen antipsychotics characteristic
Atypical, range of receptors, distinct profiles
125
Antipsychotics in the elderly
Not used in mild/moderate psychotic symptoms, initial dose half adult dose or less, review regularly
126
What drugs have most EPS symptoms
Phenothiazine (group 3 e.g. Prochlorperaxine), butyrophenones e.g. Haloperidol and 1st gen depot
127
EPS symptoms
Parkinsonian (including tremor) dystonia, dyskinesia, akathisia, tardive dyskinesia
128
Akathisia
Restlessness
129
Tardive dyskinesia
Rhythmic, involuntary movements of tongue, face, jaw
130
Dystonia
Abnormal face and body movements
131
Antipsychotic side effects
EPS, hyperprolactinaemia, sexual dysfunction, CV, hyperglycaemia, weight gain, hypotension, neuroleptic malignant syndrome, blood dyscrasias, temperature change
132
Why is hyperprolactinaemia a side effect
Dopamine inhibits prolactin release
133
Clinical symptoms of hyperprolactinaemia
Sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea
134
Sexual dysfunction and antipsychotic meds
Reduced libido, reduced ability to get an erection and ejaculation problems, switch or reduce dose if it occurs
135
Drugs that cause sexual dysfunction
Haloperidol and risperidone
136
What antipsychotics commonly cause weight gain
Clozapine and olanzapine
137
What antipsychotic drugs commonly cause hyperglycaemia
Quetiapine, risperidone
138
Antipsychotics least likely to cause diabetes
First gen, haloperidol, fluphenazine lowest risk. Amisulpride and aripiprazole are lowest of second gen
139
Antipsychotics least likely to cause weight gain
Amisulpride, aripiprazole, haloperidol, sulpiride, and trifluoperazine
140
Antipsychotics that cause postural hypotension
Clozapine, chlorpromazine, lurasidone, quetiapine
141
Neuroleptic malignant syndrome effects
Hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating, and urinary incontinence
142
Antipsychotics least likely to cause EPS
Second gen - aripiprazole, clozapine, olanzapine, and quetiapine
143
Antipsychotics least likely to cause sexual dysfunction
Aripiprazole, quetiapine
144
Antipsychotics that cause minimal hyperprolactinaemia
Second gen - aripiprazole, clozapine, olanzapine, and quetiapine
145
What to use if unresponsive to schizophrenic treatment
Clozapine if 2 or more antipsychotics used for 6-8 weeks one of which being a 2nd gen, use the clozapine for 8-10 weeks and monitor
146
Antipsychotic monitoring
FBC, Urea, electrolytes, LFT, blood lipids and weight at initiation then annually , maybe ECG and BP
147
Fasting blood glucose monitoring with antipsychotic
Baseline, 4-6 months then yearly
148
Blood lipids and weight monitoring with antipsychotic
Blood lipids and weight measured at 3 months then yearly
149
Antipsychotics used for intractable hiccup
Chlorpromazine, haloperidol
150
Downside of antipsychotic depot
Higher EPS
151
Epilepsy drugs with a long half-life
Lamotrigine, perampanel, phenobarbital, and phenytoin,
152
MHRA antiepileptic drug switching
Three categories, report via yellow card, brand name, characteristics differ
153
Category 1
Carbamazepine, phenobarbital, phenytoin, primidone. By brand/manufacturer only
154
Category 2
Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide. Clinical judgement, discussion with patient, history
155
Category 3
Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin. Can be switched
156
Epilepsy MHRA
Increased risk of suicide even one week into treatment refer mood changes, distressing thoughts, suicidal ideation
157
DVLA Epilepsy
Not drive for 6 months if unprovoked , single isolated seizure
158
Sleeping seizure DVLA policy
Can't drive for a year unless there is a history of it only happening in sleep for >1 year
159
Epilepsy and pregnancy
Teratogenic, especially valproate and topiramate (cleft hypospadias), pregnancy prevention programme warranted
160
What to do in unplanned epilepsy pregnancy
Continue drugs, use folate
161
Breast feeding and epilepsy
Continue drugs, watch for adverse symptoms in baby and withdrawal when feed stopped
162
First line focal seizure treatment
Carbamazepine, lamotrigine
163
Second line focal treatment
Sodium valproate, oxcarbazepine, levetiracetam
164
Third line/adjunctive focal treatment
When monotherapy fails combine First/second line drugs or gabapentin, topiramate, clobazam, if it doesn’t work refer
165
Generalised Tonic clonic treatment
Sodium valproate, lamotrigine if valproate ineffective or Carbamazepine, oxcarbazepine
166
Downsides to non valproate tonic treatments
Lamotrigine , carbamazepine etc. may exacerbate myoclonic seizures and absence seizures
167
Tonic clonic adjuncts
First/second line/clobazam/levetiracetam/topiramate
168
Absence generalised first line
Ethosuximide, valproate if not the lamotrigine
169
Absence adjuncts
Combination of two of ethosuximide, valproate, lamotrigine
170
Myoclonic seizures
Combination of two of ethosuximide, valproate, lamotrigine
171
Myoclonic second line treatment
Combine if not effective then specialist needed
172
Carbamazepine treats what (+downsides)
Tonic-clonic, focal, exacerbates tonic, myoclonic and absence seizures so not given to these patients
173
Oxcarbazepine treats what
Tonic-clonic, focal
174
Ethosuximide treats what
Absence
175
Gabapentin and pregabalin epilepsy treatment
Focal (pregabalin GAD)
176
Lamotrigine treats what
Tonic-clonic, focal, absence in children, atonic (second line) may exacerbate myoclonic
177
Valproate, lamotrigine relationship
Valproate increases plasma-lamotrigine
178
Levetiracetam treatment
Focal, tonic-clonic, absence(adjunct), myoclonic
179
Phenobarbital treatment
Tonic-clonic, focal - rebound seizures on withdrawal
180
Primidone and phenobarbital relationship
Primidone converted to phenobarbital so lower dose needed initually
181
Phenytoin treatment
Tonic-clonic, focal, narrow window, exacerbates absence, myoclonic
182
Topiramate treatment
Tonic-clonic, focal, lennox-gastaut, atonic, absence, tonic, myoclonic
183
Valproate treatment
Tonic-clonic, focal, myoclonic, absence
184
Valproate monitoring
LFT, FBC
185
Benzodiazepines and epilepsy
Clobazam=tonic-clonic , clonazepam = absence/myoclonic
186
Status epilipticus treatment
Pyridoxine if needed, thiamine if alcohol abuse, lorazepam or diazepam given
187
Febrile convulsions treatment
Paracetamol
188
Status epilepticus treatment
Pyridoxine if needed, thiamine if alcohol abuse, lorazepam or diazepam given.Phenytoin
189
Cluster headache treatment
Subcut sumatriptan or nasal spray or zolmitriptan nasal spray
190
Cluster headache prophylaxis
Verapamil or lithium if attacks are frequent and last over 3 weeks, prednisolone can be used for short term prophylaxis alone or with verapamil, ergotamine can be used on an intermittent basis
191
Drugs with antimuscarinic effects
Antidepressants ( amitriptyline, paroxetine), antihistamines (chlorphenamine, promethazine), antipsychotics (olanzapine, quetiapine) urinary antispasmodics ( solifenacin, tolterodine)
192
Mild-moderate Alzheimer’s treatment
Donepezil hydrochloride, galantamine, or rivastigmine (acetylcholinesterase inhibitors)
193
What to do if acetylcholinesterase inhibitors contraindicated
Memantine
194
When is memantine used
Severe Alzheimer’s and as an adjunct
195
Non-alzheimer's dementia treatment (mild to moderate dementia with lewy body)
Donepezil or rivastigmine, galantamine if both are contraindicated
196
What dementia is memantine and AChEi not recommended
Frontotemporal
197
When should AChEi or memantine be considered for vascular dementia
Suspected co-morbid Alzheimer's disease, Parkinson's disease dementia, or dementia with Lewy bodies
198
Dementia with lewy body treatment
AChEi if not then memantine
199
Severe dementia with lewy body treatment
Rivastigmine , donepezil
200
Effect of anticholinesterases on depolarising neuromuscular blocking drugs
Prolongs the action
201
Effect of anticholinesterases on non-depolarising neuromuscular blocking drugs
Reverses effects
202
Example of non-depolarising competitive neuromuscular blocking drug
Pancuronium bromide
203
Two types of competitive muscle relaxants
Aminosteroid and benzylisoquinolinuum
204
Depolarising neuromuscular blocking drugs
Suxamethonium chloride can be used with tracheal intubation
205
Competitive muscle relaxants
Aminosteroid and benzylisoquinolinuum
206
Caution to give for menstrual migraine
Medicine overuse
207
Alternative menstrual migraine prophylaxis
Zolmitriptan or frovatriptan ( relies on regular menstrual cycle)
208
Treating menstrual migraine prophylaxis
Frovatriptan +prophylactic treatment 2 days before until 3 days after menstuation (relies on regular menstrual cycle)
209
When to use botox as a migraine prophylaxis in chronic migraine
3 or more oral prophylactic treatments failed
210
What to use to prevent migraine if beta blocker unsuitable
Topiramate then TCA( amitriptyline), candesartan, valproate, pixotifen
211
Beta blockers that can be used in migraines
Propranolol, metoprolol, atenolol, nadolol and timolol
212
First line migraine prophylaxis
Propranolol
213
Domperidone MHRA warning
Not to be used in those weighing <35KG
214
Antiemetic to use in migraines
Metoclopramide and domperidone
215
Metoclopramide cautions
EPS and neurological adverse effects according to MHRA
216
Antiemetic’s that also treat headache
Metoclopramide, prochlorperazine
217
What to do if patients does not respond to monotherapy for migraines
Naproxen + sumatriptan
218
NSAIDS for vomiting migraine patients
Diclofenac suppositories
219
NSAIDs for migraine treatment
Naproxen, tolfenamic acid and diclofenac
220
Triptans for vomiting patients
Subcutaneous sumitriptan/nasal zolmitriptan
221
Alternative triptans
Almotruptan, frovtriptan, xolmitiptan
222
Triptan of choice for migraine
Sumatriptan
223
How often can triptan (5HT) be repeated
2 hours after first dose with same or different drug
224
When should triptans be taken
At the start of headache not aura
225
Firstline acute migraine
Monotherapy aspirin, ibuprofen or triptan
226
Lifestyle tips for migraine
Regular meals, hydration sleep exercise and headache diary to identify triggers for 8 weeks minimum
227
Lifestyle migraine triggers
Stress, relaxation after stress, some foods and drinks, and bright lights
228
How long do migraine aura symptoms last
Develop and resolve within an hour
229
Migraine characteristics
Recurrent attacks of typically moderate to severe headaches that usually last between 4–72 hours. unilateral, pulsating, aggravated by routine physical activity, and may impact/prevent daily activities.
nausea and vomiting, photophobia and phonophobia
230
Migraine with aura symptoms
Visual symptoms (zigzag or flickering lights, spots, lines, or loss of vision), sensory symptoms (pins and needles, or numbness), or dysphasia
231
Chronic migraine
Headache >15 days a month and migraine characteristics on at least 8 days a month
232
Episodic migraine definition
Less than 15 days a month
233
Oestrogen and migraines
Drop in oestrogen just before menstruation is a trigger
234
Chronic facial pain treatment
TCA (unlicensed)
235
Treating trigeminal neuralgia
Surgery potentially carbamazepine/phenytoin
236
Treating acute trigeminal neuralgia
Carbamazepine
237
Corticosteroid role in neuropathic pain
Helps to relieve pressure in compression neuropathy and thereby reduce pain
238
Topical neuropathic treatment
Lidocaine, capsaicin
239
Neuropathic pain treatment
TCA - amitriptyline, pregabalin
240
Treating insomnia associated with daytime anxiety
Long acting benzo e.g. Diazepam as a single night dose
241
Z drugs and MOA
Zolpidem, zopiclone hypnotics - act on benzo receptor, not licensed for long term use
242
Z drugs duration of action
Short
243
Antihistamines side effects
Headache, psychomotor impairment and antimuscarinic effects.
244
Antihistamine and insomnia things to know
Public can buy e.g. Promethazine, prolonged duration of action causes drowsiness the next day and its effect decreases after a few days of continued treatment
245
Alcohol and sleep
Poor hypnotic as it has diuretic action, it disturbs sleep patterns and worsens sleep disorders
246
Treating chronic anxiety
Benzodiazepines
247
Anxiolytic benzo treatment regimen
Lowest dose for shortest time
248
Who is benzo dependence most likely in
Alcohol or drug abuse
249
Role of beta blockers in anxiety
Reduce autonomic symptoms such as palpitation and tremor
250
Buspirone MOA
Acts on serotonin receptor
251
When is buspirone used and how long does it take for an action
Anxiety, up to 2 weeks
252
Tourette syndrome and related choreas treatment
Haloperidol, pimozide, clonidine, sulpiride, trihexyphenidyl, tetrabenazine (huntigton's chorea)
253
Essential tremor treatment
Primidone, propranolol/ beta blocker
254
Parkinson's pathophysiology
Death of dopaminergic cells in substantia nigra
255
Non-motor parkinson's disease symptoms
Dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss
256
Classic Parkinson’s symptoms
Motor symptoms hypokinesia, bradykinesia, rigidity, rest tremor, postural instability
257
Non-ergot-derived dopamine-receptor agonists
Pramipexole, ropinirole or rotigotine
258
Monoamine-oxidase-B inhibitors used in Parkinsons
Rasagiline or selegiline hydrochloride
259
What is prescribed for those whose motor symptoms decrease their quality of life
Levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa).
260
What is prescribed for those whose motor symptoms don’t decrease their quality of life
Non-ergot-derived dopamine-receptor agonists
261
Antiparkinsonian side effects
Psychotic symptoms, excessive sleepiness, sudden onset of sleep, impulse control, motor complications(levo), end of dose deterioration(levo), hallucinations
262
What side effects are more common in dopamine receptor agonists
Everything except motor complications and dose deterioration
263
Avoiding NMS and akinesia avoidance
Don’t suddenly stop antiparkinson drugs
264
What to do if a patient develops dyskinesia or motor fluctuations despite optimal levodopa
Offer non ergot DRA's, MoAbi or COMT as an adjunct if non-ergot fails then only then can you consider ergot's
265
Ergot DRA
Bromocriptine, cabergoline, pergolide
266
What to do if dyskinesia persists despite ergot/non ergot/comt etc
Amantadine
267
DVLA and parkinson's
Inform DVLA and insurer
268
Treating daytime sleepiness/sudden onset of sleep in parkinsons
Adjust treatment, give modafinil (review yearly) if reversible changes are excluded
269
Treating nocturnal akinesia
Levodopa or DRA
270
Postural hypotension in PD treatment
Midodrine if not then fludrocortisone
271
Treating hallucinations due to PD drugs
If no cognitive impairment can use quetiapine or clozapine, other antipsychotics worsen motor functions
272
Treating Rapid eye movement
Clonazepam/melatonin
273
Treating drooling
Speech and language therapy if not the glycopyrronium bromide or botox
274
Treating parkinson's dementia
Acetylcholinesterase inhibitor if not tolerated then memantine
275
Treating advanced PD
Apomorphine
276
Apomorphine side effects
QT, nausea vomiting psychiatric, confusion, subcut nodules, impulse control disorders
277
What is required when giving domperidone and apomorphine together and why
ECG due to QT prolongation risk
278
Impulse control disorders
Compulsive gambling, hypersexuality, binge eating, or obsessive shopping
279
Treating impulse control
Slowly reducing DRA
280
What is chronic pain
Lasts longer than 12 weeks (then expected)
281
Non-drug chronic treatment
Transcutaneous electrical nerve stimulation, exercise, CBT
282
CBD and chronic pain
Not recommended unless as part of a clinical trial, if already using, it may be continued until they and appropriate clinician deem it suitable to stop
283
First line WHO
Non-opioid + adjuvant if needed
284
2nd line WHO
Opioid for mild/moderate pain +/- non-opioid +/- adjuvant.
285
3rd line WHO
Opioid for moderate/severe pain +/- non-opioid +/- adjuvant
286
What are anxiolytics
Sedatives that induce sleep when given at night
287
What are hypnotics
Sedate when given during the day
288
When are benzodiazepines indicated
Short term relief of severe/disabling/distressing anxiety - 2-4 weeks only
289
What does abrupt benzodiazepine withdrawal result in
Confusion, toxic psychosis, convulsions, symptoms resembling delirium tremens
290
When does long acting benzo act cause withdrawal symptoms
3 weeks after stopping
291
When does short acting benzo act cause withdrawal symptoms
Within a day
292
Benzo withdrawal symptoms
Insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances
293
Short acting benzodiazepines
Loprazolam, lormetazepam, temazepam, no hangover effect but short acting benzos are more likely to have withdrawal phenomena
294
Long acting benzodiazepines and effects
Nitrazepam flurazepam, residual effects the next day
295
What hypnotics are used during dental procedures
Temazepam (diazepam if needed but has residual effect the next day)
296
Risk of benzodiazepines and z drugs in older patients
Ataxic risk, confusion, falls and injury so should be avoided
297
Risk of benzodiazepines and z drugs in older patients
Ataxic risk, confusion, falls and injury so should be avoided
298
Drawback of long term hypnotic use
Withdrawal can cause rebound insomnia and withdrawal syndrome
299
What antidepressant drugs can be used to promote sleep if taken at night
Clomipramine or mirtazapine
300
What is short term insomnia and length of treatment
Emotional/serious medical illness, insomnia can last for a few weeks and recur, a hypnotic should not be given for more than three weeks ideally only one week and intermittent use is preferred
301
What is transient insomnia
Normal sleeper but insomnia due to noise, shift work etc. Only one or two doses given
302
When are long acting hypnotics preferred
Poor sleep maintenance, when anxiolytic is needed during the day
303
When are short acting hypnotics preferred
When sedation the next day is undesirable or when prescribing for elderly patients
304
Considerations before giving hypnotic for insomnia
Underlying cause, alcohol consumption, realistic sleep expectations
305
How to prevent benzo withdrawal
For short acting taper within 2-4 weeks for long acting over a period of months by reducing dose by 500mcg-2mg every 2-4 weeks
306
Benzo withdrawal symptoms
Insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances
307
When does short acting benzo act cause withdrawal symptoms
Within a day
308
When does long acting benzo act cause withdrawal symptoms
3 weeks after stopping
309
What does abrupt benzodiazepine withdrawal result in
Confusion, toxic psychosis, convulsions, symptoms resembling delirium tremens
310
When is benzodiazepine used to treat insomnia
Severe/disabling/extremely distressing insomnia
311
When are benzodiazepines indicated
Short term relief of severe/disabling/distressing anxiety - 2-4 weeks only
312
When and how long should anxiolytics/hypnotics be used for
When cause has been established and short term
313
Problems with hypnotics/anxiolytics
Physical and psychological tolerance occur
