nervous system

Question 1

name the different type of dementia

Answer 1

• Alzheimer’s disease (most common)
• vascular dementia (due to cerebrovascular disease)
• dementia with Lewy bodies
• mixed dementia
• frontotemporal dementia

Question 2

what are the key symptoms related to dementia?

Answer 2

problems reasoning + communication, change in personality, reduced ability to carry out daily activities such as washing + dressing

Question 3

which HCP must initate drug treatment in newly diagnosed patient vs those currently already on drug therapy?

Answer 3

Newly diagnosed patients: initiate drug treatment under the advice of a specialist clinician

Gp may prescribe step-up treatment

Question 4

Mild to moderate Alzheimers dementia name three 1st line acetylecholinesterase inhibitors

Answer 4

1. donepezil
2. galantamine
3. rivastigmine

Question 5

what is the alternative treatment in mod alzheimers if acetylcholinesterase inhibitors are not tolerated or contra-indicated?

Answer 5

memantine (moderate disease)

Question 6

moderate-severe + severe alzhimers dementia already receiving acetylcholinesterase inhibitor step up?

Answer 6

add memantine (may initate primary care)
discontinuing acetylcholinesterase may worsen cognitive function (AVOID)

Question 7

management of mild-to-mod dementia with lewy bodies (non-alzeimers)

Answer 7

1. Donepezil [unlicensed indication]
2. rivastigmine [unlicensed indication]

Alternative: If treatment with both donepezil or rivastigmine not tolerated:
- galantamine [unlicensed indication]
Alternative: in whom acetylcholinesterase inhibitors are contra-indicated/not tolerated:
- Memantine hydrochloride [unlicensed indication]

Question 8

severe dementia with lewy bodies (monotherapy)

Answer 8

1. Donepezil hydrochloride [unlicensed indication]

2. rivastigmine [unlicensed indication]

Question 9

vascular dementia treatment if suspected co-morbid alzeimers, parkinsons disease dementia, or dementia with lewy bodies treament

Answer 9

-Acetylcholinesterase inhibitors [unlicensed indication]
OR
- memantine hydrochloride [unlicensed indication]

Question 10

Which of the following are not recommended in Frontotemporal dementia or cognitive impairment caused by multiple sclerosis:

Answer 10

X Acetylcholinesterase inhibitors

X memantine hydrochloride

Question 11

Management of cognitive symptoms of dementia - which drugs to AVOID?

Answer 11

Drugs cause antimuscarinic effects:  cognitive impairment (AVOID)

Question 12

what does cognitve symtpoms mean?

Answer 12

Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe.

Question 13

treatment of cognitive symptoms in dementia?

Answer 13

depression- antidepressants e.g. amitriptyline, paroxetine
antipsychotics e.g. olanzapine, quetiapine
antihistamine= chlorphenamine, promethazine
urinary antispasmodics e.g. solifenatic, tolterodine

Question 14

management non-cogntive symptoms of dementia

Answer 14

agitiation, aggression, distress + psychoses, depression, anxiety, sleep disturbancne
- offer counselling, CBT intial step
sleep- increase exersize and activity

Question 15

antipsyhotics and antidepressants prescribing in dementia

Answer 15

antipsychotics- only prescribe if patient risk harming themselves, or causing severe distress,
CHM: increased risk or stroke and death with antipsychoitc + elderly patient with dementia
use lowest does + review every 6 weeks
depression- reserved those pre-existing mental health problems

Question 16

what is sevre antipsychotic sensitivty reaction in those with dementia with lewy bodies or parkinson disease dementia

Answer 16

worsen motor feature of condition some case cause severe antipsychotic sensitivity reaction

Question 17

what is the mechanism of action of acetylcholinesterases?

Answer 17

reversible inhibitor of acetylcholinesterase.

examples: donepezil, galantamine, rivastigmine

Question 18

dopaminerigic drugs , NMDA receptor antagonist example and Mechanism of action

Answer 18

Memantine

DRUG ACTION =glutamate receptor antagonist

Question 19

which anti-epileptics have a long half life once daily dosing?

Answer 19

 Lamotrigine
 perampanel
 phenobarbital
 phenytoin

Question 20

Action to take if monotherapy 1st line anti-epileptic has failed?

Answer 20

• Try monotherapy with a second drug

* Note: Diagnosis should be checked before starting an alternative drug if the first drug showed lack of efficacy.

Question 21

changing one antiepileptic to another:

Answer 21

BE CAUTIOUS

• slowly withdrawing the first drug only when the new regimen has been established

Question 22

use of 2 or more antiepileptic (may be necessary)

Answer 22

• concurrent use of antiepileptic drugs increases the risk of adverse effects and drug interactions.
• If combination therapy does not bring about worthwhile benefits, revert to the regimen (monotherapy or combination therapy) that provided the best balance between tolerability and efficacy.
 A single antiepileptic drug should be prescribed wherever possible.

Question 23

MHRA: antiepileptics advice on switching brands

Answer 23

• potential harm of switching patient stabilised

- report of loss seizure, worsening SEs, explained as chance associations, casual role of switching cannot be ruled out

Question 24

minimise risk of swithcing anti-epileptics brands?

Answer 24

3 risk categories
if desirable GP must specifiy product, prescribe brand or generic + manufacturer name
advice relates to only treatment of epilepsy
report yellow card scheme any suspected ADR
pharmacist ensure continuity of supply ,

Question 25

action if a specific brand not available

Answer 25

it may be necessary to dispense a product from a different manufacturer to maintain continuity of treatment of that antiepileptic drug. Such cases should be discussed and agreed with both the prescriber and patient (or carer):

Question 26

category 1 antiepileptics must be maintained specific manufacturer product

Answer 26

``` [CPPP]  Carbamazepine  phenobarbital  phenytoin  primidone ```

Question 27

category 2- maintain brand based on clinical judgement, based on seizure frequency, treatment history, potential implication of patient having breakthrough seizure, + consider non-clinical factors

Answer 27

``` [CROP CEL TVZ]  Clobazam  rufinamide  oxcarbazepine  perampanel ```  clonazepam  Eslicarbazepine acetate  lamotrigine  topiramate  valproate  zonisamide.

Question 28

category 3 (doesnt matter)- uncessary maintain specific manufacturer brand consider product name, packaging, appearance, etc + consider patient disability

Answer 28

``` [BELL TV GP]  Brivaraceta  ethosuximide  lacosamide  levetiracetam ```  tiagabine  vigabatrin  gabapentin  pregabalin

Question 29

what is antiepileptic hypersensitivty syndrome

Answer 29

rare fatal syndrome associated some antiepileptics

Question 30

risk of antiepileptic hypersensitivty syndrome with the following drugs

Answer 30

``` [ROLL C PPP]  rufinamide  oxcarbazepine  lacosamide  lamotrigine  Carbamazepine  phenobarbital  phenytoin  Primidone ``` theoretical risk:  Eslicarbazepine  stiripentol  Zonisamide

Question 31

symptoms of antiepileptic hypersensitivty syndrome?

Answer 31

``` Symptoms (week 1-8 of exposure): most common:  fever  rash  lymphadenopathy Other systemic signs:  liver dysfunction  Haematological  renal, and pulmonary abnormalities  vasculitis  multi-organ failure ```

Question 32

action to take if hypersensitivty occurs anti-epileptics

Answer 32

If signs or symptoms occur the drug should be withdrawn immediately!!! the patient must not be re-exposed, and expert advice should be sought

Question 33

MHRA alert for all anti-epileptics

Answer 33

MHRA advised all antiepileptic drugs are associated with a small increased risk of suicidal thoughts and behaviour. Symptoms may occur as early as one week after starting treatment Advise patients to report: • mood changes • distressing thoughts • feelings about suicide or harming themselves

Question 34

interaction with anti-epileptics

Answer 34

* may increase toxicity without an increase in antiepileptic effect * usually caused by hepatic enzyme induction or inhibition * Displacement from protein binding sites is not usually a problem. * Interactions are highly variable and unpredictable

Question 35

antiepileptic withdrawal

Answer 35

withdrawn under specialist supervision 1. Avoid abrupt withdrawal, particularly of barbiturates and benzodiazepines, because this can precipitate severe rebound seizures. 2. Reduction in dosage should be gradual+ case of barbiturates, withdrawal of the drug may take months! 3. The decision to withdraw antiepileptic from a seizure-free patient, and its timing, is often difficult and depends on individual circumstances. 4. Even in patient’s seizure-free for several years, a significant risk of seizure recurrence on drug withdrawal 5. In patients receiving several antiepileptic drugs, only one drug should be withdrawn at a time.