Nervous system Flashcards
1
Q
Which classes of drugs have anitmuscarinic (anticholinergic) burden?
A
Antimuscarinic drugs result in cognitive impairment (use minimised in dementia)
- antidepressants (e.g. amitriptyline & paroxetine)
- antihistamines (e.g. chlorphenamine & promethazine)
- antipsychotics (e.g. olazapine & quetiapine)
- urinary spasmodics (solifenacin & tolterodine)
2
Q
How do you treat cognitive symptoms in mild-moderate Alzheimer’s disease?
A
1st line: Acetylcholinesterase inhibitors - monotherapy with donepezil, galantamine, or rivastigmine
2nd line: memantine (in moderate AD)
3
Q
How do you treat cognitive symptoms in severe Alzheimer’s disease?
A
1st line: memantine
If pt already receiving Acetylcholinesterse inhibitor already, the addition of memantine can be started in primary care
4
Q
How do you treat cognitive symptoms in mild-to-moderate non-alzheimer’s dementia?
A
Donepezil or rivastigmine in mild-moderate non-alzheimer’s dementia with Lewy bodies
- if both not tolerated then galantamine can be considered
5
Q
How do you treat cognitive symptoms in severe non-alzheimer’s dementia?
A
Donepezil or rivastigmine in severe non-alzheimer’s dementia with Lewy bodies
- C/I or not tolerated = memantine
6
Q
When can memantine be considered to treat cognitive symptoms in non-alzheimer’s dementia?
A
In patients with vascular dementia if they have suspected co-morbid AD, parkinsons disease dementia or dementia with Lewy bodies
7
Q
Who are acetylcholinesterase inhibitors and memantine contraindicated in?
A
Patient with frontotemportal dementia or cognitive impairment caused by multiple sclerosis
8
Q
What should you consider before treating agitation, aggression, distress and psychosis in patient with dementia?
A
Antipsychotics should ONLY be considered if:
- Pt is at risk of harming themselves or others
- experiencing agitation, hallucinations or delusions that are causing severe distress
9
Q
What is the MHRA warning for antipsychotics and dementia?
A
Increases risk of stroke and small increases risk of death when antipsychotics are used in elderly patient WITH dementia
Assess risks v benefits
- including previous history of stroke or TIA
- risk factors for cerebrovascular disease: e.g. hypertension, diabetes, smoking and AF
10
Q
If antipsychotic medication is decided to commence in patients with dementia, when should they be reviewed?
A
Every 6 weeks
Treat with the lowest dose for the shortest period of time
11
Q
What types of dementia do antipsychotics worsen?
A
Patient with dementia with lewy bodies or parkinsons disease dementia - antipsychotic drugs worsen motor features of condition and in some cases cause antipsychotic sensitivity reactions
12
Q
How is depression and anxiety treated in dementia?
A
Psychological treatments for mild-moderate dementia - CBT, multi-sensory stimulation, relaxation or animal-assisted therapies
Antidepressants should be reserved for pre-existing severe mental health problems
13
Q
What is the STOPP criteria for donepezil, galantamine and rivastigmine?
A
- known history of persistent bradycardia
- HR less than 60 beats per minute
- heart block
- recurrent unexplained syncope
- concurrent treatments with drugs that reduce HR
14
Q
What is the patient and carer advise for galantamine?
A
Warn of the signs of serious skin reactions - advised to stop taking immediately and seek medical advise (steven-johnsons syndrome)
15
Q
When should rivastigmine treatment be interrupted?
A
If dehydration resulting in prolonged vomiting or diarrhoea occurs and withheld until resolution - retitrate dose if necessary
16
Q
What is the conversion between oral rivastigmine and transdermal patch?
A
Taking between 3-9mg orally = start with 4.6mg/24 hr patch
Taking 9mg orally = switch to 9.5mg/24hr patch
Taking 12mg orally = switch to 9.5mg/24 hr patch
Patch can be started the day following last oral dose
Transdermal patches less likely to cause side effects
17
Q
Where do you apply the rivastigmine patch?
A
clean, dry, non-hairy, non-irritated skin on:
- back
- arm
- check
Removing after 24 hours
Avoid using the same area for 14 days
18
Q
Which anti-epileptics have a long half-life and can be taken OD at night?
A
Lamotrigine
Perampanel
Phenobarbital
Phenytoin
19
Q
What are the MHRA warnings for anti-epileptic drugs?
A
- risk of suicidal thoughts and behaviours (symptoms may occur as early as 1 week after starting treatment)
- advice on switching between different manufacturer’s products
- teratogenicity: valportate must not be used in females of child-bearing age unless conditions of the PPP are met and alternative treatments contraindicated or not appropriate
20
Q
What anti-epileptic drugs are category 1 and should be prescribed and maintained on a specific brand?
A
Carbamazepine
Phenobarbital
Phenytoin
Primidone
21
Q
What anti-epileptic drugs are category 2 and prescribing by brand is based on clinical judgment and the patient?
A
Clobazam
Clonazepam
Lamotrigine
Topiramate
Valporate
22
Q
Which drugs is anti-epileptic hypersensitivity syndrome associated with?
A
Carbamazepine
Lacosamide
Lamotrigine
Oxcarbazepine
Phenobarbital
Primidone
Rufinamide
Symptoms start between 1-8 weeks of exposure
Withdraw drug immediately - do not re-expose
23
Q
What are the symptoms of hypersensitivity syndrome?
A
common: fever, rash and lymphadenopathy
other systemic signs: liver dysfunction, haematological, renal and pulmonary abnormalities, vasculitis and multi-organ failure
24
Q
Which anti-epileptics can precipitate severe rebound seizures if stopped abruptly?
A
Barbiturates
Benzodiiazepines
25
How do you withdraw anti-epileptic medication?
Patient should be seizure for 2 years at least
Assessment to determine seizure recurrence should be carried out
Withdrawal should do done over a minimum of 3 months
If a seizure occurs during this process - the last dose reduction should be reversed and clinicians must seek advise from epilepsy specialist
26
How long must patients who have had an unprovoked or single isolated seizure not drive for?
6 months
27
How long must patients with established epilepsy not drive for?
Must be seizure free for at least 1 year or have a pattern of seizures established for one year where there is no influence on their level of consciousness or their ability to act
They must also have no history of unprovoked seizures
28
What are the exemptions for people who have seizures while asleep?
They must not drive for a year from last date of seizure unless:
- a history or pattern of sleep seizure's occurring ONLY ever while asleep has been established over the course of at least one year from the date of the first sleep seizure
- an established pattern of purely asleep seizures can be demonstrated over the course of 3 years if the patient has previously had seizures whilst awake (or awake and asleep)
29
What should patients take if on anti-epileptics and becomes pregnant?
Folate especially during the first trimester is recommended
30
How do you minimise the risk of neonatal haemorrhage associated with anti-epileptics?
Routine injection of vitamin K
31
Who should pregnant females with epilepsy be encourages to notify?
Epilepsy and Pregnancy Register
32
Which anti-epileptics are readily transferred into breast-milk causing high infant serum-drug concentrations?
ethosuximide
Lamotrigine
primidone
zonisamide
33
Which anti-epileptics slow metabolism in infants causing it to accumulate?
Phenobarbital
Lamotrigine
34
Which anti-epileptics have established risk of drowsiness in breast-fed babies?
Primidone
Phenobarbital
Benzodiazepines
35
Which anti-epileptics may cause withdrawal effect if mother suddenly stops breast-feeding?
Phenobarbital
Primidone
Lamotrigine
36
How do you treat focal seizures with or without secondary generalisation?
1st line: monotherapy with lamotrigine or levetiracetam
2nd line: monotherapy with carbamazepine, oxcarbazepine or zonisamide
3rd line: lacosamide
Conjunctive therapy:
1st line: carbamazepine, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, topiramate
2nd line: brivaracetam, cenobamate, eslicarbazepine, perampanel, pregabalin, sodium valporate (in males and females unable to have children)
3rd line: phenobarbital, phenytoin, tiagabine, vigabatrin
37
How do you treat tonic-clonic generalised seizures?
Males or females unable to have children:
1st line: sodium valporate
2nd line: lamotrigine or levetiracetam
Females who are able to have children:
1st line: lamotrigine or levetiracetam
Adjunctive treatment
1st line: clobazam, lamotrigine, levetiracetam, perampanel, sodium valporate (men and females unable to have children), or topiramate
2nd line: brivaracetam, lacosamide, phenobarbital, primidone, zonisamide
38
How do you treat generalised absence seizures?
1st line: ethosuximide
2nd line: sodium valpoerate as monotherapy or adjunctive therapy for males and females unable to have children
3rd line: monotherapy or adjunctive therapy with lamotrigine or levetiracetam
39
How do you treat generalised myoclonic seizures?
1st line: sodium valporate
2nd line: levetiracetam (1st line if females of childbearing age) monotherapy or adjunctive
40
How do you treat generalised atonic or tonic seizures?
Usually seen in childhood
1st line: sodium valproate
2nd line: lamotrigine monotherapy or adjunctive (1st line in females of childbearing age)
41
Which type of epilepsy is associated with cerebral damage or learning difficulties?
Atonic or tonic seizures
42
How do you treat Dravet's syndrome?
1st line: sodium valporate in all patients (ensure PPP)
If monotherapy fails, consider triple therapy: Sodium valporate + clobazam + stiripentol
Cannibidiol with clobazam may be considered as 2nd line in certain patients
43
How do you treat lennox gastaut syndrome?
1st line: sodium valporate in all patients (PPP)
2nd line: lamotrigine monotherapy or adjunctive therapy
3rd line: adjunctive therapy with cannabidiol + clobazam
44
What is considered as a repeated or cluster seizure?
3 or more self-terminating seizures in 24 hours
45
What is considered as a prolonged convulsive seizure?
A seizure that continued for 2 minutes longer than the usual patients seizure
46
What is considered as convulsive status epilepticus?
A seizure that lasts for 5 minutes or more - medical emergency
47
How are repeated/ cluster seizures or prolonged seizures treated?
1st line: individualised emergency management plan
2nd line: benzodiazepine e.g. clobazam or midazolam urgently considered
48
How do you treat convulsive status epilepticus?
- position to avoid injury
- support respiratory : provision or oxygen, maintaining BP and correction of any hypoglycaemia
- consider parenteral thiamine if alcohol abuse suspected
1. patients individualised emergency plan
2. urgent buccal midazolam or rectal diazepam if in community
- if resuscitation resources available then IV lorazepam
Call emergency services and if 1st dose doesnt work, provide a 2nd dose after 5-10 minutes
No response to 2 doses of benzodiazepines: levetiracetam, phenytoin or sodium valporate
3rd line: phenobarbital or general anaesthesia
49
How do you treat convulsive status epilepticus if caused by pyridoxine deficiency (vitamin B6)?
Pyridoxine hydrochloride
50
How do you treat non-convulsive status epilepticus?
Depends of severity of condition
If incomplete loss of awareness = usual antiepileptic therapy should be continued or restarted
Fail to respond/ lack of awareness = treat the same way as convulsive status epilepticus
51
Which antiepileptic drugs do MRHA suggest vitamin D supplementation in immobilised patients or those lacking exposure to sunlight or dietary intake of calcium?
Carbamazepine and phenytoin
52
What are the cautions for carbamazepine?
Blood, hepatic of skin disorders
HLA allele
53
What is the optimum plasma concentration response range for carbamazepine?
4-12mg/L OR
20-50micromol/L
Measured after 1-2 weeks
54
What additional MHRA warnings doses gabapentin have?
Risk of respiratory depression
Risk of abuse and dependence: now sch 3
55
What is a serious side effect of lamotrigine?
Serious skin reactions - Stevens-Johnson syndrome and toxic epidermal necrolysis have developed (especially in children)
Most rashes occur within 8 weeks
Factors associated with this: rapid dose increase, use with valporate and initial high dose
56
What is the additional MHRA warning for pregabalin?
Respiratory depression
57
What is the additional MHRA warning for phenytoin?
risk of death and severe harm from error with injectable phenytoin
58
What is the additional MHRA warning for topiramate?
Start of safety review triggered by a study reporting an increased risk of neurodevelopmental disabilities (e.g. autism) in children with prenatal exposure
59
When can drug treatment be commenced in ADHD?
In patient with ADHD whose symptoms are still causing significant impairment in at least one area of function despite environmental modifications
60
How do you treat ADHD?
1st line: lisdexamfetamine or methylphenidate (6 week trial)
(dexamfetamine can be tried if the patient is having beneficial reponse to lisdexamfetamine but cannot tolerate its longer duration of effect
2nd lime: atomexetine
3rd line: guanfacine
61
What is the patient and carer advise for atomoxetine?
suicidal ideation
hepatic impairment
62
What are the administration instructions for guanfacine
avoid administration with hifh fat meals - may increase absorption
63
When should antidepressants be avoided in bipolar disporder?
In patients with rapid-cycling bipolar disorder, a recent history or mania or hypomania or with rapid mood fluctuations
64
What is used to treat acute episodes of mania or hypomania?
Antipsychotics: haloperidol, olanzapine, quetiapine and risperidone
if inadequate response: lithium or valporate may be added
65
How do you treat moderate to severe manic episodes associated with bipolar?
Asenapine - second generation antipsychotic
66
What is used for long-term management of bipolar?
Olanzapine - licensed for prevention of recurrence in patients whose manic episode has responded to olanzapine therapy
67
What is the minimum time antipsychotics should be discontinued over?
4 weeks
68
When are benzodiazepines used in bipolar?
(e.g. lorazepam)
May be helpful in initial stages of treatment for behavioural disturbance or agitation
Do not use for long periods due to risk of dependence
69
How long does the prophylactic effect of lithium take to occur?
6-12 months after initiating therpy
70
When is valproic acid used in bipolar?
Used for treatment of manic episodes associated with bipolar is lithium not tolerated or contraindicated
71
When is carbamazepine used in bipolar?
long-term management to prevent recurrence of acute episodes in patients unresponsive to lithium therapy
72
What are the specific side effects for valproic acid?
hepatic dysfunction - withdraw treatment immediately symptoms develop
Pancreatitis - discontinue if symptoms develop
73
What is the criteria for chronic depression?
for at least 2 years, either continually meet the criteria for diagnosis of major depression episodes, or have persistent subthreshold symptoms, or persistent low mood (with or without concurrent episodes of major depression)
74
What is the initial treatment for depression?
The use of antidepressants and/ or psychological or psychosocial treatment
75
When should patients on antidepressants be reviewed?
2-4 weeks for after initiation
Those at high risk of suicide or ages 18-25 should be reviewed 1 week after staring treatment or increasing dose
Effects seen within 4 weeks (6 weeks in elderly) and continue treatment for at least 6 months (12 months in elderly and patients being treated for anxiety)
76
How do you treat subthreshold or mild depression?
1st line: psychological and psychosocial therapy
2nd line: antidepressants if patient preference
- SSRI: citalopram, escitalopram, sertraline, fluoxetine, fluvoxamine or paroxetine
77
How do you treat moderate or severe depression?
1st line: combination therapy + antidepressants
- SSRI
2nd line: SNRI
- duloxetine or venlafaxine
78
Which class of antidepressants have the highest risk of overdose?
TCA
79
Which TCA has the best safety profile?
Lofepramine
80
What can be used in severe depression if rapid response is required?
electroconvulsive therapy
81
What can used if a patient has limited or no response to at least 2 antidepressants?
Vortioxetine
82
Which antidepressant is safest for patient who had recent MI or has unstable angina?
Sertraline
83
Which class of antidepressants have highest association with hyponatraemia?
SSRIs
consider hyponatraeia in all patients with symptoms including drowsiness, confusion, or convulsions
84
Which class of drugs is serotonin syndrome associated with?
MOAI
85
What are the symptoms of serotonin syndrome?
Neuromuscular hyperactivity - tremor, hyperreflexia, clonus, myoclonus, rigidity
Autonomic dysfunction - tachycardia, BP changes, hyperthermia, diaphoresis, shivering, diarrhoea
Altered mental state - agitation, confusion, mania
86
How do you treat anxiety?
usually benzodiazepines or buspirone
Chronic anxiety: antidepressant - can be combined with benzo until antidepressant takes effect
- SSRI e.g. escitalopram, paroxetine or sertraline
- 2nd line: SNRI - duloxetine ir venlafaxine
-3rd line: pregabaline
87
How do you treat panic disorders?
SSRI
2nd line: clomipramine or imipramine
Venlafaxine also licensed for panic disorders
88
How is OCD/ PTSD treated?
SSRI
2nd line: clomipramine
89
Which drug is licensed for social anxiety?
Moclobemide
90
Which tricyclics are more sedating?
Clomipramine
Dosulepin
Doxepin
Mianserin
Trazodone
Trimipramine
91
Which tricyclics are less sedating?
Imipramine
lofepramine
nortriptyline
92
Which MAOI has greater stimulant action is likely to cause hypertensive crisis?
Tranylcypromine
93
Which MAOI should be reserved for 2nd line?
Moclobemide (reversible MAOI)
94
What should be done when stopped an MAOI but started other antidepressants?
Do not start another antidepressant for 2 weeks after MAOI stopped but 3 weeks if staring clomipramine or imipramine
95
What should be done when stopping an antidepressant and starting an MAOI?
Do not start MAOI until:
- at least 2 weeks after previous MAOI has been stopped (then start at reduced dose)
- at least 7-14 days after tricyclic (3 weeks if clomipramine or imipramine) has been nstopped
- at least a week after am SSRI (5 weeks in the case of fluoxetine) has been stopped
96
What are the specific MAOI side effects?
Postural hypotension and hypertensive responses
Discontinue if palpitations or frequent headaches occur
97
What are the contraindicated of MAOIs?
Cerebrovascular disease
Not indicated for manic phase
Phaeochromocytoma
Severe cardiovascular disease
98
What is the patient and carer advise foe MAOIs?
Eat only fresh foods, avoid stale or going off foods
Danger of interaction persists for 2 weeks after stopping drug
Avoid alcoholic or de-alcoholised drinks
May cause drowsiness
Avoid foods and beverages containing tyramine - e.g. cheese, salami. herring, oxo, marmite, beers, largers, wines
99
What is the MHRA warning for SSRIs/SNRIs?
small increased risk of postpartum haemorrhage when used in the month before delivery
100
What are the contraindications of SSRIs?
Poorly controlled epilepsy
Should not be used if patients enters manic phase
101
What are the specific side effects of SSRIs?
Sexual dysfunction may persist after treatment has stopped
SSRIs can cause GI bleeds
102
Which the contraindication for citalopram and escitalopram?
Prolonged QT
103
What is the maximum citalopram dose in hepatic impairment?
20mg
104
Which SSRI has a higher risk of withdrawal reactions?
Paroxetine
105
What is the contraindication for venlafaxine
uncontrolled hypertension
106
What are the contraindications for amitriptyline?
Arrhythmias
During manic phase of bipolar
heart block
Immediate recovery period after MI
107
Which drug is used for control of deviant antisocial sexual behaviours?
Benperidol
108
What are the positive symptoms of psychosis?
Hallucinations
Delusions
109
What are the negative symptoms of psychosis?
Emotional empathy
Social withdrawal
110
Which psychosis symptoms are antipsychotics better at alleviating?
Positive symptoms
111
How long do patients need to be on antipsychotics before they are deemed unsuccessful?
At optimum dose frr 4-6 weeks
112
When is the only time 2 antipsychotics can be prescribed at the same time?
Clozapine augmentation OR
when changing medication during titration
113
What are the risks associated with prescribing 2 antipsychotics?
Extrapyrimadol side effects
QT prolongation
Sudeen cardiac death
114
When can clozapine be prescribed for schizophrenia?
When there has been sequential use of at least 2 different antipsychotics (1 of which should be 2nd generation antipsychotic) each for an adequate time and could not control schizophrenia
Allow 8-10 weeks to assess response - patient must be registered with clozapine patient monitoring service
115
What would you consider if patient not adhering to antipsychotic for psychosis and schizophrenia?
Long-acting depot injectable antipsychotic drugs
116
Which antipsychotics are more likely to cause extrapyramidal symptoms and hyperprolactinaemia?
first-generation antipsychotic drugs
e.g. piperazine
Phenothiazines
butyrophenones
Depot preparations
117
Name some 1st generation antipsychotics (typical/conventional)
Phenothiazine derivatives - chlorpromazine, fluphenazine, levomepromazine, pericyazine, prochlorperazine, promazine, trifluperazine
Butyrophenones - benperidol, haloperidol
Thioxanthenes - flupentixol, zuclopenthixol
Diphenylbutylpiperidines - pimozide
Substituted benzamides - sulpiride
118
Name some 2nd generation antipsychotics (atypical)
Amisulpride
Aripiprazole
Asenapine
Cariprazine
Clozapine
Paliperidone
Quetiapine
Risperidone
119
What adverse effects are 2nd generation antipsychotics associated with?
Glucose intolerance
Weight gain
120
How should antipsychotics be prescribed in emergency situations?
Initial prescription should be written as a single dose
oral and IM drugs should be prescribed separately
121
What are the risks of antipsychotics in elderly patients with dementia?
Increased risk of mortality
Increased risk of stroke and TIA
Higher risk of postural hypotension
122
When can antipsychotics be used in elderly patients with dementia?
When there is a risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing themselves severe distress
Lowest effective dose for shortest time
Patient should be reviewed at least every 6 weeks
123
What should be considered in patients with learning disabilities taking antipsychotics but not experiencing psychotic symptoms?
- reduction in dose or discontinuation
- reviewing patients condition after dose reduction or discontinuation
- refer to psychiatrist experienced in working with the patient
- annual documentation of reasons for continuing and not reducing or discontinuing
124
Which 2nd generation antipsychotics are associated with late-onset extrapyramidal symptoms?
Clozapine
Olanzapine
Quetiapine
Aripiprazole
125
What are extrapyramidal parkinsonian symptoms?
Bradykineasia - slow movement and speed
Tremor
126
Who are extrapyramidal parkinsonian symptoms more common in?
Female elderly patients
Those with pre-existing neurological damage e.g. stroke and may appear gradually
127
What are extrapyramidal dystonia symptoms?
Uncontrolled muscle spasms in any part of the body
128
Who are extrapyramidal dystonia symptoms more common in?
Young males
Can appear within hours of starting antipsychotics
129
What are extrapyramidal akathisia symptoms?
Restlessness - start within hours to weeks of starting antipsychotics or dose increase and can be mistaken for psychotic agitation
130
What are extrapyramidal tardive dyskinesia symptoms?
Abnormal involuntary movements of lips, tongue, face and jaw - can develop on long-term or high-dose therapy, or even after discontinuation
in some patients, it can irreversible
More common in elderly females
131
Which antipsychotic drugs are most likely to cause hyperprolactinaemia?
Risperadone
Amisulpride
Sulpiride
First generation antipsychotics
132
Which antipsychotic reduces prolactin concentration in a dose-dependent manner?
Aripiprazole
133
What are the symptoms of hyperprolactinaemia?
Sexual dysfunction
Reduced bone mineral density
Menstrual disturbances
Breast enlargement
Galactorrhoea
Increased risk of breast cancer
134
Which antipsychotic drugs have a lowest association with sexual dysfunction?
Aripiprazole
Quetiapine
135
Which antipsychotic drugs have a highest association with sexual dysfunction?
Riseperidone
Haloperidol
Olanzapine
136
Which cardiovascular side effects are associated with antipsychotics?
Tachycardia
Arrhythmias
Hypotension
137
Which antipsychotic is concerned with QT prolongation
pimozide
Also high risk in patients using IV antipsychotics or combination of antipsychotics whose doses exceed recommended amount
138
Which type of antipsychotics are most likely to cause postural hypotension?
2nd generation - clozapine and quetiapine
139
Which type of antipsychotics is most likely to cause diabetes?
2nd generation are more likely to cause diabetes
- amisulpride and aripiprazole have the lowest risk
From 1st generation antipsychotics - fluphenazine and haloperidol have the lowest risk of this
140
Which antipsychotics are associated with weight gain?
Clozapine and olanzapine
141
What are the symptoms of neuroleptic malignant syndrome?
Rare but fatal side effect of all antipsychotics
Hyperthermia. fluctuating level of consciousness, muscle rigidity, autonomic dysfunction with fever, tachycardia, liable BP and sweating
142
How should you act if neuroleptic malignant syndrome is suspected with antipsychotics?
Discontinue drug for at least 5 days preferably longer - symptoms should be allowed to resolve completely
Bromocriptine and dantrolene have been used for treatment
143
What is the monitoring requirements for antipsychotics?
Weight - baseline then weekly for 6 weeks then 12 weeks then yearly
Fasting glucose, HbA1c, blood lipid concentration - baseline, 12 weeks, yearly
Prolactin - baseline, 6 months then yearly
ECG - before treatment
BP - before treatment, 12 weeks, yearly
FBC, urea, electrolytes, LFTs - start of therapy and yearly
144
What if the MHRA warning for clozapine and other antipsychotics?
Monitoring blood concentration for toxicity
145
Which antipsychotic should pharmacists, nurses and other HCP be warned about handling?
chlorpromazine - risk of contact sensation
146
What are the safety and MHRA warnings for haloperidol?
Safety - no to confuse the IM/SC injections with depot preparations of haloperidol decanoate
MHRA - risks when used in elderly patients for acute treatment of delirium: increased risk of adverse neurological and cardiac effects
147
What are the oral and parenteral specific side effects for haloperidol?
Oral - angioedema
Parenteral - hypertension and severe cutaneous adverse reactions (SCARs)
148
What is the specific caution for prochlorperazine?
Hypothyroidism
149
What are the specific side effects for prochlorperazine?
With buccal use: blood disorders and hepatic disorders
150
Which 1st generation antipsychotics are available as depot injections?
No more than 2-3ml of oily injection at any one site
Flupentixol deconate
Haloperidol deconate
Zuclopenthixol deconate
151
What are the MHRA warnings for clozapine?
Potential fatal risk of intestinal obstruction, faecal impaction and paralytic ileus
Monitoring blood concentrations for toxicity
152
What is a specific caution for clozapine?
Agranulocytosis - neutropenia and potentially fatal agranulocytosis
Myocarditis and cardiomyopathy (most common in first 2 months)
Intestinal obstruction
153
How do you teat hypersalvation with clozapine?
hyoscine hydrobromide provided that the patient is not at risk of additive antimuscarinic side effects
154
What are common specific side effects of olanzapine?
IM: dyslipidaemia
Oral: hypersomnia
155
Which 2nd generation antipsychotics are available as depot injections?
Olanzapine embonate
156
How do you treat muscular symptoms of motor neurone disease?
1st line: Quinine
2nd line: baclofen
Subsequent treatment: tizanidine, dantrolene or gabapentin
157
How do you treat saliva problems in motor neurone disease?
Trial of antimuscarinic for excessive drooling of saliva
- glycopyrronium recommended in patients who have cognitive impairment as has fewer central nervous system side effects
2nd line: botulinum toxin type A
Treating thick, tenacious saliva - humidification, nebulisers and carboscisteinne
158
How do you treat breathlessness in motor neurone disease?
benzodiazepines or opioids
159
How do you treat amyotrophic lateral sclerosis in motor neurone disease?
Riluzole
160
What is used to control movement disorders in Huntington's chorea and related disorders?
Terabenazine - also used for tardive dyskinesia if switching or withdrawing causative antipsychotic
Haloperidol, olanzapine, risperidone, quetiapine - also used to suppress chorea in Huntington's disease
161
What is used to treat tourette's syndrome and related choreas?
Haloperidol - improves motor tics
Pimozide (ECG monitoring required), clonidine, sulpiride,
162
How do you relieve intractable hiccups?
Chlorpromazine and haloperidol
163
How do you treat tremors associated with anxiety and thyrotoxicosis?
Propranolol and other beta blockers
Benginin essential tremor - primidone
164
What is the first line management of Parkinson's disease in patients who's motor symptoms are decreasing their QoL?
Levodopa combined with either carbidopa or benserazide (co-careldopa or co-benldopa)
165
What is the first line management of Parkinson's disease in patients whos motor symptoms are NOT decreasing their QoL?
Levodopa OR
non-ergot-derived dopamine-receptor agonists: pramipexole, ropinirole, rotigotine OR
Monoamine-oxidase-B inhibitors: rasagiline or selegiline
166
What type of side effects are expected with antiparkinsonian drugs?
Psychotic symptoms
Excessive sleepiness
Sudden onset of sleep - especially dopamine receptor agonists
Impulse control
167
What motor complication is levadopa associated with?
Response fluctuations and dyskinesia
If end-of-dose deterioration = MR tablets
168
How do you treat daytime sleepiness and sudden onset of sleep in parkinsons?
Modafinil - review every 12 months
169
How do you treat nocturnal akinesia in parkinsons?
1st line: levodopa or oral dopamine-receptor agonists
2nd line: rotigotine
170
How do you treat postural hypotension in parkinsons?
1st line: midodrine
2nd line: fludrocortisone
171
How do you treat hallucinations and delusions and parkinsons?
patient with no cognitive impairment:
- 1st: quetiapine
- 2nd: clozapine
172
How do you treat rapid eye movement sleep disorder behaviour in parkinsons?
clonazapam
173
How do you treat drooling of saliva in parkinsons?
1st line: glycopyrronium
2nd line: botulinium toxin type A
Risk of cognitive adverse effects
- topical atropine
174
Which antiemetic can be used for chemo and radiotherapy induced N/V and is less sedating?
Prochlorperazine
175
Which antiemetic is used for N/V in palliative care?
Haloperidol
176
Which antiemetic is less likely to cause central effects?
Domperidone - it does not cross the BBB
Central effects examples:
- sedation
- dystonic reactions
177
Which antiemetic is used to treat N/V in parkinsons caused by dopaminergic drugs?
Domperidone
178
Which anti-emetics are used to prevent N/V from cytotoxics?
Ondansetron
Granisetron
Palonosetron
Palonosetron with netupitant
179
Which antiemetics are used in chemo-therapy induced N/V?
dexamethasone
aprepitant
180
What drug can be considered as add-on therapy for chemotherapy induced N/V when unresponsive to conventional antiemetic?
Nabilone - a synthetic cannabinoid with antiemetic properties
181
Which food can be helpful for pregnant women experiencing prolonged N/V?
Ginger
182
Which antiemetic options are there for N/V in pregnancy?
Chlorpromazine
Metoclopramide
Cyclizine
Doxylamine with pyridoxine
Prochlorperazine
Promethazine *
Ondansetron
183
Which antiemetics are used for post-operative N/V?
Granisetron
Ondansetron
Dexamethasone
Droperidol
Cyclizine - licensed for prevention and treatment of post-op N/V caused by opioids and general anaesthesia
184
Which antiemetic is licensed for motion sickness?
Hyoscine
Antihistamines
185
What is the MHRA warning for metoclopramide?
risk of neurological adverse effects - use only for 5 days
10mg TDS
186
Which antiemetic should be avoided in GI problems or obstruction?
Metoclopramide
(3-4 days after GI surgery)
187
What is the MHRA warning for ondansetron?
small increased risk of oral clefts following use in first 12 weeks of pregnancy
188
What is the definition of chronic pain?
Pain that persists more than 12 weels
189
What is a common co-morbidity of chronic pain?
Depression
190
Which analgesic should be avoided in pain in sickle-cell disease?
Pethidine because accumulation of neurotoxic metabolite can precipitate seizures
191
Which analgesic does naloxone only partially reverse?
Buprenorphine
192
Which analgesic has greater solubility and so allowed effective doses to be injected in smaller volumes?
Diamorphine hydrochloride (heroin)
193
What is the maximum number of times methadone can be administered per day?
twice to avoid risk of accumulation
194
How do you treat a cluster headache?
Sumatriptan s/c
if unsuitable - sumatriptan nasal spray or zolmitriptan nasal spray
195
What is considered as prophylaxis of cluster headache?
frequent attacks last of 3 weeks
196
What is the treatment for prophylaxis cluster headache?
Verapamil or lithium
197
What is used short-term for prophylaxis of episodic cluster headaches?
Prednisolone monotherapy or in combination with verapamil
198
What are the characteristics of a migraine?
Recurrent attacks of typically moderate-severe headaches lasting between 4-72 hours
Unilateral, pulsating, aggravated by routine physical activity
Usually accompanied by N/V, photophobia and phonophobia or both
199
What is a migraine WITH aura?
Consists of visual symptoms
- zigzag/ flickering lights, spots, lines or loss of vision
- dysphasia
- sensory symptoms e.g. pins and needles and numbness
200
What is considered as an episodic migraine?
headache which occurs less than 15 days per month
- low frequency = 1-9 days
- high frequency 10-14 days
201
What is considered as a chronic migraine?
Headache which occurs on at least 15 days per month and has characteristics of a migraine on at least 8 days per month for greater than 3 months
202
What is the first line treatment for acute migraine?
aspirin, ibuprofen or a triptan (sumatriptan drug of choice)
Should be taken as soon as patient knows they are developing a migraine
203
How should patients with migraines with aura take triptans?
Take at the start of the headache and not at the start of aura unless they both happen at the same time
Treatment can be repeated after 2 hours with the same or different drug if there was inadequate response
204
What should be used in patients presenting with severe N/V in acute migraines?
diclofenac sodium suppositories
205
What should be given to patients with acute migraines if they fail to response to monotherapy?
Sumatriptan and naproxen
206
Which antiemetics can be given to relieve N/V in acute migraines?
Metoclopramide or prochlorperazine
Domperidone - alternative
207
What is recommended treatment for preventative migraine treatment?
1st line: Propranolol - episodic or chronic migraine
- unsuitable: other beta blockers
2nd line: topiramate (risks of birth defects - highly effective contraception)
other drugs that can be used
- amitriptyline
- candesartan
These should be used for at least 3 months before considering it ineffective - a good response is a 50% reduction in severity and frequency of migraines
3 or more prophylactic treatments ineffective - botox
208
How do you treat menstrual migraine prophylaxis?
Frovatriptan - instead of or in addition to standard prophylactic treatment
- 2 days before until 3 days after menstruation starts
Alternatives: zolmitriptan or naratriptan
Patient must have regular cycle for medication to be effective
209
What is recommended for postherpetic neuralgia?
Capsaicin
210
What is recommended for trigeminal neuralgia?
Carbamazepine - reduces frequency and severity of attachs
211
What are the characteristics of benzodiazepines withdrawal syndrome?
isnomnia
anxiety
loss of appetite and body weight
tremor
perspiration
tinnitus
perceptual disturbances
Can occur up to 3 weeks after stopping
212
What is the recommended withdrawal regimen for diazepam?
reduce by 1-2mg every 2-4 weeks: in patients taking higher doses it may be suitable to reduce by 1/10th every 1-2 weeks
Towards end of withdrawal may be necessary to reduce in steps of2 500mcg
213
What are the risks of hypnotics and z-drugs in elderly patients?
risk of becoming ataxic and confused leading to falls and injury
214
Which benzodiazepines are used as hypnotics?
Nitrazepam and flurazepam - longer acting
Loprazolam, lormetazepam and temazepam - shorted acting (little to no hangover effect)
215
Which hypnotic is referred in elderly?
Clomethiazole - freedom from hangover
216
What is the treatment for precipitated withdrawal with buprenorphine?
Lofexidine if symptoms are severe
217
How do you reduce the risk of precipitated withdrawal?
first dose of buprenorphine should be given when patient is exhibiting signs of withdrawal or 6-12 hours after last use of heroin or 24-48 hours after last dose of methadone
218
When is methadone initiated?
at least 8 hours after last heroin dose
219
When is methadone and buprenorphine withdrawal preferable in pregnancy?
during second trimester with dose reductions made every 3-5 days
- first trimester poses a risk of spontaneous miscarriage
- third trimester not recommended because of maternal withdrawal
220
What are the symptoms of neonatal withdrawal?
High-pitched cry
Rapid breathing
Hungry but ineffective suckling
Excessive wakefulness
Severe but rare symptoms include - hypertonicity and convulsions
221
What is used to attenuate alcohol withdrawal symptoms?
Chlordiazepoxide or diazepam
Carbamazepine
Clomethiazole - if taking with alcohol can lead to fatal respiratory depression (particularly with cirrhosis)
222
What is used first line for delirium tremens and alcohol-induced seizure?
Lorazepam
223
What should be used in patients with mild alcohol dependence where psychological intervention alone not successful?
Acamprosate calcium or oral naltrexone
224
What is recommended for reducing alcohol consuming in patients who have a high risk drinking level?
Nalmefene
225
What are the preferred options for stop smoking drug treatment?
Varenicline (unavailable in the UK)
Long-acting NRT - patch
Short-acting NRT - lozenges, gum, sublingual tablets, inhalator, nasal and oral spray
If not appropriate - use bupropion or single therapy NRT
Do not combine therapies
226
What is the MHRA warning for bupropion?
risk of serotonin syndrome when used with other serotonergic drugs
227
What is the treatment for depression in childnre?
1st line: fluxoetine 10mg (Can be increased up to 20mg after a week if required)
2nd line: sertraline ot citalopram
228
Which drugs should NOT be used in the treatment of depression in children and young people?
Paroxetine
Venlafaxine
TCAs
229
What is the normal serum lithium concentration?
0.4-1 mmol/L
Target in acute mania: 0.8-1 mmol/L
230
What do MAOIs interact with to cause hypertensive crisis?
Tyramine rich food
Ephedrine or pseudoephedrine
Levodopa
Stimulants e.g. methylphenidate and amphetamine
231
What predisposes patients to seratonin syndrome with MAOIs?
Tramadol
Other antidepressants
232
What predisposes patients to CNS excitation or depression with MAOIs?
Tramadol
Pholcodine
Opioids
Avoid the above during MAOI treatment and for 14 days after stopping the MAOI
233
What are the side effects of methylphenidate?
Decreased appetite
Growth retardation
CV abnormalities
Psychiatric symptoms
Hypertension
Arrhythmia
In children - monitor weight and height every 6 months
234
Which benzodiazepines are short-acting?
<1-12 hours
Midazolam
Oxazepam
Triazolam
235
Which benzodiazepines are intermediate acting?
12-24 hours
Flunitrazepam
Lorazepam
Alprazolam
Clonazepam
Temazepam
236
Which benzodiazepines are long-acting?
>24 hours
Flurazepam
Nitrazepam
Chlordiazepoxide
Diazepam
237
What are the anti-cholinergic side effects?
Dry mouth
Blurred vision
Urinary retention
Constipation
238
What is used for extrapyrimadole side effects?
Procyclidine
239
What are the ADRs of atypical antipsychotics?
Weight gain
Dyslipidaemia
Diabetes
Drowsiness
Reduced seizure threshold
Anticholinergic side effects
Hyperprolactinaemia
- ED
- Galactorrhoea
- Gynaecomastia
CV effects
- Postural hypotension
- QT prolongation
240
What are the ADRs of clozapine?
Agranulocytosis
Neutropenia
Hypersalivation
Constipation
Cardiomyopathy
Myocarditis
Intestinal obstruction
241
What are the SSRI interactions?
NSAIDs - risk of bleeding (PPI if given together)
Warfarin/Heparin/NOAC - risk of bleeding
Aspirin - risk of bleeding
Triptans - risk of sertonin syndrome
MAOIs - risk of sertonin syndrome
Drugs that prolonged QT with citalopram e.g. antipsychotics
242
What is antidote for benzodiazepines?
Flumazenil
243
What is antidote for antidepressants?
Activated charcoal
IV loarzepam od diazepam
Sodium bicarbonate
244
What is antidote for lithium?
Haemodialysis
Gastric lavage
245
What is antidote for stimulant drugs?
Diazepam or lorazepam
246
What is antidote for iron?
Desfferioxamine
247
For which drugs do you need to screen test for HLA-B*1502 allele in Han-chinese and thai patients before treatment?
Carbamazepines
Phenytoin
Higher risk of stevens-johnson syndrome
248
What are the interactions of lithium?
Diuretics especially thiazides - increases lithium concentration
ACEi/ARBs - increases lithium concentration
NSAIDs - increases lithium concentration
Metronidazole - increases lithium concentration
Iodine salts - risk of hypothyroidism
Carbamazepine - risk of neurotoxicity
Antipsychotics - QT prolongation
249
Which anti-epileptic can be prescribed by a dentist?
Carbamazepine for forms of neuralgia
250
What are the side effects of carbamazepine?
GI upset - N/V
Neurological effects - ataxia and dizziness
Oedema
Hyponatraemia
251
Which parkinsons medication turns urine colour reddish-brown?
Entacapone
252
Which antiepileptics are enzyme inducers?
Carbamazepine
Phenobarbital
Eslicarbazepine
Oxcarbazepine
Phenytoin
Primidone
253
What is the contraindication of tramadol?
Uncontrolled epilsepsy
254
Which anti-epileptic drugs does not reduce the effectiveness of oral contraception?
Lamotrigine
255
What is the maximum dose of citalopram in patients ages 65+?
20mg
256
Which OTC product reduces lithium concentrations?
Antacids containing sodium bicarbonate increase lithium excretion
257
What records are kept in the lithium therapy record book?
Lithium blood results
TFTs
Renal checks
Weight/ BMI
258
What is the maximum total duration of therapy when using clomethiazole for alcohol withdrawal?
9 days
259
Which antiemetic is considered safe in parkinsons diease?
Domperidone - doesn't cross BBB
2nd line - ondansetron but causes constipation
260
Which antiemetics worsen parkinsons disease?
Metoclopramide
Haloperidol
Prochlorperazine
261
Which test should be done monthly before supple of clozapine
White blood cells - due to risk of fatal agranulocytosis
262
What is donepezil associated with?
Neuroleptic malignant syndrome
263
What is galantamine associated with?
Serious skin reactions - stop at first sign of rash (stevens-johnson syndrome)
264
What is rivastigmine associated with?
GI problems - withhold
265
What are cholinergic side effects?
DUMB BELS
Diarrhoea
Urination
Muscle weakness/ miosis (small pupils)
Bronchospasm
Bradycardia
Emesis (vomiting)
Lacrimation (tears)
Salivation
(opposite of antimuscarinic effects)
266
Which antiepileptic drugs are in high amounts in breastmilk?
ZELP
Zosinamide
Ethosuximide
Lamotrigine
Primidone
267
What is the treatment for menstruation epilepsy?
Acetazolamide
268
What is the only benzodiazepine that can be prescribed for alcohol withdrawal?
Chlordiazepoxide hydrochloride
269
What is the interaction between phenytoin and ciprofloxacin?
Can increase or decrease the concentration of phenytoin
270
What if the interaction between phenytoin and St Johns Worts?
Decrease in phenytoin serum concentration
271
Which triptan drug requires dose adjustments when given with propranolol?
Rizatriptan
272
What is a common SSRI electrolyte imbalance?
Hyponatraemia
- n/v
- confusion
- headache
273
When is a lithium level taken?
12 hours after dose otherwise levels may be too high but not accurate
274
What needs to be monitored for clozepine?
Neutropenia
275
is the maintenance dose of donepezil?
10mg ON
276
Which acetylcholinesterase causes sleep probelms?
Donepezil - try changing dose to the morning time
277
What do you do if the patient is experiencing bradycardia with donepezil?
Stop donepezil and start memantine - giving them another acetylcholinesterase is not helpful because they have the similar side effects
278
What is the therapeutic range for phenytoin?
10-20mg/L
279
What increases the risk of phenytoin toxicity?
Hypoalbuminaemia
Hepatic impairment
Hyperbilirubinaemia
280
What are the signs of phenytoin toxicity?
- nystagmus (involuntary movement of the eyes)
- diplopia/blurred vision
- slurred speech
- ataxia
- confusion
- hyperglycaemia
281
Which antidepressant used for chronic pain has an anticholinergic burden?
Amitriptyline (TCAs)
282
What are the side effects of phenytoin?
- Agranulocytosis
- Skin rashes, toxic epidermal necrolysis
- Suicidal thoughts
- Low vitamin D- rickets, osteomalacia
283
Which drug causes a sudden onset of sleep?
Levodopa
284
How much time should be left in between different levodopa preperations?
At least 12 hours
285
Which drug requires regular monitoring of neutrophils and leucocytes?
Clozapine
286
Which drug is licensed for treating Meniere's disease?
prochlorperazine
286
What is a licensed treatment for behavioural and psychological symptoms of Alzeihmers disease?
Risperidone
287
Which antidepressant is associated with weight gain?
Mirtazapine
288
Which anti-emetic is associated with muscle-rigidity, movement disorders, tremor and parkinsonism?
Droperidol
289
What factors slow down metabolism of antipsychotics?
Females
Geriatric age
Non-smokig status
290
How long should remission period last for antidepressants?
6 months
12 months - in elderly and those being treated for generalised anxiety
2 years in patients with recurrent remission
291
Which TCA has more marked anti-muscarinic effects?
Imipramine
292
What is the counselling for antipsychotics?
Photosensitisation may occur with higher doses - avoid direct sunlight
293
Which drugs can aid smoking cessation and be used alongside behavioural support?
Varenicline and bupropion
294
Which Parkinson’s Medication is more likely to cause impulse reactions?
Non-ergot derived! More than levodopa
E.g. pramipexole, ropinirole, rotigotine
295
Which CNS drugs tend to cause hyponatraemia?
SSRIs
Carbamazepine
(diuretics and desmopressin too)
296
What side effects do non-ergot derived drugs cause?
Pramipexole, ropinirole, rotigotine
- impulse disorders
- sudden onset of bleed
- hypotensio
297
What is usually prescribed for wernicke's encephalopathy?
thiamine (b1)
298
What are paradoxical side effects of benzodiazepines and how is it treated?
SE: increase talkativeness, emotional release, excitement, excessive movement, hostility and aggression
It is essentially benzodiazepine toxicity = treat with flumazenil
299
How often is clozapine monitored?
weekly for first 18 weeks
fortnightly from 18 weeks - 52 weeks
Then monthly
Blood lipids and weight - baseline then every 3 months
Fasting blood glucose - at baseline, after 1 month then every 4-6 months
300
What is the age restriction for domperidone?
12+
301
What is offered for advanced parkinsons disease with 'off episodes'?
apomorphine hydrochloride as intermittent injections or continuous subcutaneous infusions
- if pt experiences nausea and vomiting with this = domperidone started 2 days before apomorphine
--> assess cardiac risk factor first due serious arrhythmia from to prolonged QT
302
What are some important methadone interactions?
Citalopram, amiodarone, aripiprazole, tetracyclines - QT prolongation
Clarithromycin increases methadone exposure
Bendroflumethiazide, budesonide, betamethasone - hypokalaemia
303
Which drugs are likely to cause seratonin syndrome?
SSRI
TCA
Triptans
Tramadol
Lithium
304
Which benzodiazepines have a driving limit?
COLD FeeT
Clonazepam
Oxazepam
Lorazepam
Diazepam
Flunitrazepam
Temazepam
305
What colour can amitriptyline colour urine?
Greenish-blue
305
What are the signs of carbamazepine toxicity?
HANGBAGS
Hyponatraemia
Ataxia
Nystagmus
Drowsiness
Blurred vision
Arrhythmia
GI disturbances
306
Which 1st generation antipsychotics have the least extrapyramidal side effects?
Group 2 phenothiazines:
pericyazine
307
Which 1st generation antipsychotics have the highest risk of extrapyramimdal side effects?
Group 3 phenothiazines:
fluphenazine, prochlorperazine and trifluoperazine
Also:
Benperidol and haloperidol
308
What antidepressants does tamoxifen interact with?
Fluoxetine and paroxetine - they decrease efficacy of tamoxifen
309
Which drug reduces your visual field?
Vigabatrin
310
Which benzodiazepine is not associated with blood dyscrasias?
Clonazepam
