Nervous System - High Flashcards
(341 cards)
1
Q
What is the drug of choice for patients with severe Alzheimer’s disease?
A
Memantine hydrochloride
1
Q
What are the first line options for the treatment of mild-moderate Alzheimer’s disease?
A
- Donepezil
- Galantamine
- Rivastigmine
2
Q
Which drug class does memantine belong to?
A
NMDA receptor antagonists
(Dopaminergic)
3
Q
What are the MHRA warnings associated with the use of antiepileptics?
A
- Risk of suicidal thoughts and behaviours (August 2008)
- Updated advice on switching between manufacturers products (November 2017)
4
Q
Which MHRA risk category is Carbemazepine in?
A
Category 1
5
Q
Which MHRA risk category is phenytoin in?
A
Category 1
6
Q
Which MHRA risk category is phenobarbital in?
A
Category 1
7
Q
Which MHRA risk category is primidone in?
A
Category 1
8
Q
Which MHRA risk category is clonazepam in?
A
Category 2
9
Q
Which MHRA risk category is clobazam in?
A
Category 2
10
Q
Which MHRA risk category is lamotrigine in?
A
Category 2
11
Q
Which MHRA risk category is sodium valproate in?
A
Category 2
12
Q
Which MHRA risk category is topiramate in?
A
Category 2
13
Q
Which MHRA risk category is gabapentin in?
A
Category 3
14
Q
Which MHRA risk category is pregabalin in?
A
Category 3
15
Q
Which MHRA risk category is levetiracetam in?
A
Category 3
16
Q
What are the categories assigned by the MHRA to antiepileptic drugs and what do they signifiy?
A
- Catgeory 1 - Patients must be mainatined on a manufacturer’s specific product
- Category 2 - Patients can be switched but factors such as seizure frequency, treatment history, and potential implications should be considered and discussed with the patient beofre switching to another product
- Category 3 - It is unnecessary for patients to be maintained on a specific manufacturer’s product
17
Q
How should treatment with antiepileptic drugs be stopped?
A
Withdrawn gradually under specialist supervision to prevent rebound seizures.
18
Q
Which antiepileptics can be used during pregnancy?
A
Levetiracetam and lamotrigine
19
Q
What is the difference between focal and generalised seizures?
A
- Focal - signals originate in one part of the brain
- Generalised - All areas of the brain are affected by an abnormal electrical impulse
20
Q
What are the first line options for the treatment of focal seizures, with or without secondary generalisation?
A
Carbemazepine
OR
Lamotrigine
21
Q
What is the first line option for the treatment of tonic-clonic seizures?
A
Sodium valproate
Lamotrigine (monotherapy or adjunct) where valproate not appropriate
22
Q
What are the first line options for the treatment of absence seizures?
A
Ethosuximide
OR
Sodium valproate
23
Q
What are the first line options for the treatment of myoclonic seizures?
A
Sodium valproate
OR
Levetiracetam
OR
Topiramate
24
What is the first line option for the treatment of atonic and tonic seizures?
Sodium valproate
25
Which seizure types is carbepazepine not recommended in?
Tonic-clonic
Atonic and tonic
Absense
Myoclonic
26
Which seizure type is carbemazepine the second-line treatment option for?
Focal seizures
27
What is ethosuximide a first line treatment for?
Absence seizures
28
What are pregabalin and gabapentin indicated for?
- Focal seizures
- Neuropathic pain
- Pregabalin is indicated for treatment of generalised anxiety disorder
29
What type of seizure is the use of gabapentin and pregabalin **not** recommended in?
Tonic-clonic
Atonic and tonic
Myoclonic
Absense
30
What are the types of generalised seizures?
- Tonic-clonic
- Atonic and tonic
- Absence
- Myoclonic
31
What is lamotrigine the first line treatment option for?
- Focal seizures
- Primary and secondary tonic-clonic seizures (where sodium valproate has been unsuccessful)
32
How does lamotrigine interact with other antiepileptic drugs?
- Sodium valproate increases lamotrigine plasma concentration
- Enzyme inducing antiepileptics decrease lamotrigine serum concentrations
33
What is levetiracetam indicated for?
Focal seizures as monotherapy and adjunct
34
What is phenobarbital indicated for?
Focal seizures
Tonic-clonic seizures
35
What is primidone metabolised into?
Phenobarbital
36
What type is seizures is phenytoin indicated for?
Focal seizures
Tonic-clonic seizures
37
Which type of seizures can phenytoin exacerbate?
Absence seizures
Myoclonic seizures
38
What type of seizures is topiramate indicated for?
Focal seizures
Tonic-clonic seizures
39
Sodium valproate is the first line choice for epilepsy with which seizure types?
Tonic-clonic
Myoclonic
Atonic-tonic
40
How should seizures lasting longer than 5 minutes be treated?
IV lorazepam
41
If seizures fail to respond to initial treatment after 25 minutes, what action should be taken?
Phenytoin or phenobarbital should be used and emergency services should be contacted
42
If seizures fail to respond to treatment 45 minutes after onset, what action should be taken?
IV midazolam should be used or another anaesthesia
43
What are the MHRA warnings are associated specifically with the use of gabapentin?
- (Neurontin) Risk of severe respiratory depression (October 2017)
- Risk of abuse and dependence: New scheduling requirements (April 2019)
## Footnote
Levels of propylene glycol, acesulfame K and saccharin sodium may exceed daily intake limits if high doses oral solution (Bosemont brand) are given to adolescents or adults with low body weight (39-50kg)
44
What is the MHRA warning specifically associated with the use of sodium valproate?
Contraindicated in women and girls of child bearing potential unless conditions of pregnancy prevention prgramme are met (April 2018)
45
List some enzyme inducing drugs
- Carbemazepine
- Rifampicin
- Phenytoin
- Phenobarbitone
- Sulphonylureas
- Griseofulvin
- St John's wort
46
List some enzyme inhibiting drugs
- Metronidazole
- Sodium valproate
- Erythromycin
- Isoniazid
- Cimetidine
- Chloramphenicol
- Ciprofloxacin
- Omeprazole
- Sulfonamides
- Ketoconazole
47
List some drugs that have an anticholinergic burden
- Amitriptyline
- Paroxetine
- Chorphenamine
- Promethazine
- Olanzapine
- Quetiapine
- Solifenacin
- Tolterodine
48
What are the most commonly prescribed acetylcholinesterase inhibitors?
Donepezil
Rivastigmine
49
What are the acetylcholinestaerase inhibitors indicated for?
1. Mild to moderate Alzheimer's
2. Mild to moderate Parkinson's (rivastigmine)
50
What are some important adverse effects associated with the use of acetylcholinesterase inhibitors?
- GI upset
- Exacerbation of asthma and COPD symptoms
- Peptic ulcers
- Bradycardia
- Heart block
- Hallucinations
- Altered behaviour
- Neuroleptic malignant syndrome
51
When should acetylcholinesterase inhibitors be used with caution?
- Asthma and COPD
- Peptic ulcers
52
When should the use of acetylcholinesterase inhibitors be avoided?
- Bradycardia
- Heart block
53
Which drugs do acetylcholinesterase inhibitors interact with an to what extent?
- NSAIDs - increased risk of ulcers and GI blleds
- Corticosteroids - increased risk of ulcers and GI bleeds
- Beta-blockers - increased risk of bradycardia and heart block
- Antipsychotics - increased risk of neuroleptic malignant syndrome
54
Which drug class does donepezil belong to?
Acetylcholinesterase inhibitors
55
Which drug class does rivastigmine belong to?
Acetylcholinesterase inhibitors
56
What is phenobarbital indicated for?
All types of seizures except absence seizures
57
Whe should phenobarbital be used with caution?
- Elderly
- Acute porphyrias (avoid)
- Respiratory depression
- Alcohol abuse
58
Is phenobarbital an enzyme inducer or inhibitor?
Inducer
59
Which drug shares cross-sensitivity with phenobarbital?
Carbemazepine
60
What are some important adverse effects associated with the use of phenobarbital?
- Hepatic disorders
- Bone disorders
- Agranulocytosis
- Changes in mood
61
What are some adverse effects associated with the use of phenytoin?
- Blood disorders
- Skin disorders
- Bone disorders
- Cardiac disorders
- Respiratory disorders
62
What is are some key points when counselling a patient on the use of phenytoin?
Important that they recognise the signs and symptoms of blood and skin disorders
63
Can phenytoin be used in pregnancy and breastfeeding?
Pregnancy - no
Breastfeeding - yes
64
Phenytoin may exacerbate which kinds of seizures?
Absence
Myoclonic
65
How does phenytoin affect enteral feeding regimens?
Enteral feed needs to be interupted 2 hours before and after dose
66
Which demographic of patients can phenytoin not be used in and why?
Those of Han chinese or Thai origin - increased risk of Stevens-Johnson's syndrome
67
What monitoring requirements are there for the use of phenytoin?
FBCs
68
What class of drugs do phenobarbital and primidone belong to?
Barbiturates
69
What is the MHRA warning associated with the use of benzodiazepines?
Benzodiazepines and opioids: Risk of potentially fatal respiratory depression (March 2020)
70
What are sodium valpraote and valproic acid indicated for?
1. Prophylaxis of seizures in epilepsy
2. Status epilepticus where a benzodiazepine has been unsuccessful
3. Bipolar disorder
71
Prophylaxis of which types of seizure is sodium valproate the first line treatement for?
Focal
Tonic-clonic
Absence
Myoclonic
72
What are the important adverse effects associated with the use of valproate?
- GI upset
- Neurological and psychiatric effects
- Thrombocytopenia
- Severe liver injury
- Bone marrow failure
- Pancreatitis
73
When is the use of sodium valproate contraindicated?
- Women of child bearing potential
- Pregnancy, particularly in the first trimester
74
Which drugs interact with valproate?
- Drugs that are metabolised by CYP enzymes (warfarin etc)
- Enzyme inhibitors - increase the toxicity and risk of adverse effects
- Enzyme inducers - lower the efficacy valproate and increase risk of seizures
- Drugs that lower the seizure threshold (antipsychotics and tramadol)
75
How is sodium valproate metabolised?
By hepatic CYP enzymes
76
What are the key points when counselling a patient on the use of sodium valproate?
1. GI upset is transient and will likely pass in a few days
2. Aware of signs and symptoms of liver and blood abnormalities
3. Discuss pregnancy and contraception
4. Patient cannot drive unless thay have been seizure free for 12 months and for 6 months after switching or stopping treatment
77
What are the clinical indications for the use of carbemazepine?
1. Seizure prophylaxis
2. Trigeminal neuralgia
78
Which seizure type is the use of carbemazepine not recommended in?
Myoclonic
Absence
79
What are the important adverse effects associated with the use of carbemazepine?
- Antiepileptic hypersensitivity syndrome
- GI upset
- Neurological effects
- Oedema
- Hyponatraemia
## Footnote
Carbemazepine causes oedema and hyponatraemia through antidiuretic hormone-like effects
80
When should carbemazepine be used with caution?
- Renal impairment
- Hepatic impairment
- Cardiac disease
- Pregnancy
81
When is the use of carbemazepine contraindicated?
In patients with a history of antiepileptic hypersensitivity syndrome
82
Is carbemazepine an enzyme inucer or inhibitor?
Inducer
83
Which drugs interact with carbemazepine and to what extent?
- Drugs that are metabolised by CYP enzyme such as warfarin, oestrogen and progestogens
- CYP inhibitors - increase risk of adverse effects and toxicity
- Other antiepileptics
- Drugs that lower the seizuere threshold such as antipsychotics an tramadol
84
How should carbemazepine be initiated?
Started at a low dose of 100 - 200mg OD/BD then increased gradually (max 1.6g)
85
What are the clinical indications for the use of lamotrigine?
1. Prophylaxis of focal, tonic-clonic, and absence seizures in epilepsy
2. Bipolar depression
86
What are the important adverse effects associated with the use of lamotrigine?
- Headache
- Drowsiness
- Blurred vision
- GI upset
- Skin rash
- Hypersensitivity reactions
87
When is a dose reduction of lamotrigine necessary and why?
Patients with hepatic impairment as lamotrigine is metabolised by glucuronidation
88
Can lamotrigine be used in pregnancy?
Yes
89
Which drugs interact with lamotrigine and to what extent?
- Drugs that induce glucuronidation such as carbemazepine, oestrogens, rifampicin, and protease inhibitors - cause lamotrigine concentrations to fall
- Valproate inhibits glucuronidation and as such causes the concentration of lamotrigine to rise increasing the risk of toxicity
90
What should happen to the dose of lamotrigine if it is being coprescribed with a drug that causes glucuronidation?
It should be doubled
91
How is lamotrigine typically dosed?
Started at 25mg OD
Increased 2-weekly intervals up to 200mg
92
What should happen to the dose of lamotrigine if it is taken concurrently with valproate?
It should be halved or taken on alternative days
93
How is lamotrigine unique as a treatment for bipolar disorder?
It effectively treats bipolar depression without increasing the risk of switch to mania
94
What are the clinical indications for the use of levetiracetam?
1. Prophylaxis of focal seizures
2. Status epilepticus when first line benzodiazepine was ineffective
## Footnote
It can also be used for the treatment ofmyoclonic and tonic0clonic seizures
95
What are the advantages of using levetiractem compared to other antiepileptics?
It is relatively well tolerated, and most patients only suffer from mild adverse effects or none at all.
It also has very few clinically significant interactions with other drugs such as hormonal contraception, warfarin, and other antiepileptc drugs
96
Can levetiracetam be used during pregnancy and breastfeeding?
Yes
97
When is a dose adjustment of levetiracetam required?
In renal impairment
98
What is a typical dosing regimen of levetiracetam?
Starting dose of 500mg BD
Increased to 1g after 2 weeks (max 1.5g BD)
99
What is the dose equivalance between oral and IV levetiracetam
They are the same
100
What are gabapentin and pregabalin indicated for?
1. Add-ons for the prophylaxis of focal seizures in epilepsy
2. First line options for neuropathic pain
3. Pregabalin is licensed in generalised anxiety disorder
101
What are the main adverse effects associated with the use of gabapentin and pregabalin?
Drowsiness
Dizziness
Ataxia
## Footnote
These improve after a few weeks of treatment
102
When should both gabapentin and pregabalin be dose adjusted?
In renal impairment
103
Which drugs interact with gabapentin and pregabalin and to what effect?
Their sedating effect maybe exacerbated by other sedating drugs such as benzodiazepines
Other than that they have relatively few significant clinical indications
104
How should gabapentin and pregabalin be initiated?
They should be started at a low dose and gradually titrated up to reduce adverse effects
105
Between gabapentin and pregabalin, which has an effect on urine dipstick testsing?
Gabapentin can cause false positives for proteins on urine dipstick tests
106
What are the most commonly prescribed benzodiazepines?
Chlordiazepoxide
Lorazepam
Diazepam
Temazepam
Midazolam
107
What are the clinical indications for the use of benzodiazepines?
1. First line management of seizures and status epilepticus
2. Fisrt line management of alcohol withdrawal reactions
3. Sedation for intervention procedures
4. Short-term treatment of severe or distressing anxiety or insomnia
108
What are the important adverse effects associated with the use of benzodiazepines?
- Drowsiness
- Dependence
- Withdrawal reactions
- Small chance of cardiorespiratory depression
109
Which benzodiazepine is the best choice for the treatment of alcohol withdrawal in a patient with liver failure and why?
Lorazepam as it depends less on liver elimination and therefore has a lesser chance of causing hepatic encephalopathy
110
In which patient demographic should benzodiazepines be used with particular caution and why?
The elderly as they are more susceptible tothe effects of benzodiazepines
111
When should the use of benzodiazepines be avoided?
- Liver failure
- Respiratory impairment
- Neuromuscular disease
112
Which drugs interact with benzodiazepines and to what effect?
- Other drugs with sedating effects such as opioids and alcohol
- CYP inhibitors such as metronidazole
113
For the treatment of alcohol withdrawal is it best to use a long- or short-acting benzodiazepine?
Long
## Footnote
Such as chlordiazepoxide, lorazepam, and diazepam
114
For the treatment of epilepsy is it best to use a long- or short-acting benzodiazepine?
Long
## Footnote
Usually lorazepam
115
For sedation is it best to use a long- or short-acting benzodiazepine?
Short
## Footnote
Such as midazolam
116
What duration of action is ideal in a benzodiazepine used to treat anxiety and insomnia?
Intermediate
## Footnote
Tenazepam
117
Which drug is a specific antagonist of benzodiazepines?
Flumazenil
118
Why is the use of flumazenil rarely indicated?
It should not be used to reverse benzodiazepine-induced sedation in suspected overdose as it may precipitate seizures, which having blocked the action of the benzodiazepines will extremely difficult to treat
119
What is the NHS Never Event regarding midazolam?
Mis-selection of high strength midazolam during conscious sedation (January 2018)
120
What is a typical dose of chlordiazepoxide for the treatment of alcohol withdrawal?
10 - 40mg QD
Reduced over 5 - 7 days
121
What are the first line options for the treatment of ADHD?
Methylphenidate
Lisdexamfetamine
122
What schedule of CD is methylphenidate?
Schedule 2
123
What drug is sold under the brand name Delmosart?
Methylphenidate
124
What drug is sold under the brand name Concerta?
Methylphenidate
125
What drug is sold under the brand name Medikinet?
Methylphenidate
126
When is the use of methylphenidate contraindicated?
- Cardiovascular disease
- Hyperthyroidism
- Psychosis
- Anorexia
127
What drug is sold under the brand name Elvanse?
Lisdexamfetamine
128
What schedule of CD is lisdexamfetamine?
Schedule 2
129
Can either methylphenidate or lisdexamfetamine be used in pregnancy or breastfeeding?
No
130
What is the next line option for the treatment for patients in whom stimulants have been ineffective or are unsuitable for the treatment of ADHD?
Guanfacine
131
Which drug class does guanfacine belong to?
Alpha2-adrenoreceptor agonists
132
What needs to be monitored in patients receiving treatment with guanfacine?
- QT interval
- Hypotension
- Bradycardia
- Arrythmia
- BMI
133
Which drugs are used to treat acute episodes or mania and hypomania?
Olanzapine
Haloperidol
Quetiapine
Risperidone
134
Which drugs are used for the prophylaxis of mania and hypomania?
Lithium
Valproate
135
What does lithium interact with and to what extent?
ACE inhibitors - increases the risk of lithium toxicity
136
What are the clinical indications for the SSRIs?
1. Depression
2. Panic disorder
3. OCD
137
What are the important adverse effets associated with the use of SSRIs?
- GI upset
- QT prolongation
- Increased bleeding risk
- Serotonin syndrome
- Lower seizure threshold
- Hyponatraemia
## Footnote
Withdrawal side effects - GI upset, flu-like symptoms, and sleeplessness
138
When should SSRIs be used with caution?
- History of peptic ulcers
- Epilepcy
139
Which drugs cannot be given alongside SSRIs?
- Monoamine oxidase inhibitors
- Serotinergic drugs
140
Which drugs interact with SSRIs and to what extent?
- Serotinergic drugs and MAO inhibitors - precipitate serontin syndrome
- Aspirin and NSAIDs - increased risk of bleeding
- Anticoagulants - increased risk of bleeding
- Drugs that prolong QT (amiodarone, antipsychotics, quinine, quinolones, macrolides)
141
Which SSRI has the lowest chance of withdrawal side effects?
Fluoxetine
## Footnote
Half life - 14 days
142
What is the most commonly prescribed tricyclic antidepressant?
Amitriptyline
143
Which drug class does venlafaxine belong to?
SNRIs
144
What are the clinical indications for the use of tricyclic antidepressants?
1. Second-line treatment for depression
2. Neuropathic pain (unlicensed)
145
What are the important adverse effects associated with the use of tricyclic antidepressants?
- Antimuscarinic effects such as dru mouth and urinary retention
- Sedation
- Hypotension
- Arrythmias
- QT prolongation
- Convulsions
- Breast changes
- Extrapyramidal symptoms
146
Use of tricyclic antidepressants can make which conditions worse?
- Prostatic hypertrophy
- Glaucoma
- Constipation
147
When should tricyclic antidepressants be used with caution?
- Elderly
- Epilepsy
- Cardiovascular disease
148
Which drugs interact with tricyclic antidepressants and to what extent?
- MAO inhibitors - increased risk of hypertension, hyperthermia, and serotonin syndrome
- Antimuscarinics - enhanced effects
- Antihypertensives - enhanced hypotensive effects
- Sedatives - enhanced effects
149
Which tricyclic antidepressant has a lesser adverse effect profile than the rest of the drugs in the class?
Lofepramine
150
What is a typical dose of amitriptyline for the treartment of neuropathic pain?
10mg ON
151
What is atypical strting dose of amitriptyline for the treatment of depression?
75mg OD
152
What is good practice with regards to the supply of tricyclic antidepressants such as amitriptyline?
Supply a short course - usually 2 weeks
153
Which drug class does mirtazapine belong to?
Tetracyclic antidepressants
154
What are the clinical indications for the use of venlafaxine?
1. Second-line in depression where SSRIs have been unsuccessful
2. Generalised anxiety disorder
155
What are the clinical indications for the use of mirtazapine?
1. Second-line in depression where the SSRIs have been unsuccessful
2. Sedation in elderly
156
Is venlafaxine is associated with a higher or lower incidence of adverse effects than other antidepressants?
Higher
157
What are some important adverse effects associated with the use of venlafaxine?
- GI upset
- Neurological effects
- Hyponatraemia
- Serotonin syndrome
- QT prolongation
158
What arethe important adverse effects associated with the use of mirtazapine?
- Agranulocytosis
- GI upset
- Sedation
- Hyponatraemia
- Seotonin syndrome
159
When should venlafaxine be used with caution?
- Elderly
- Arrythmias
- Renal and hepatic impairment
160
Which drugs interact with venlafaxine and to what extenet?
- Antidepressants such as SSRIs increse risk of serotonin syndrome
161
What is a typical dose of venlafaxine?
37.5mg BD (titrated up 375mg MDD)
162
Is mirtazapine more sedating at a higher or lower dose?
Lower
163
What is the key point when counselling patients on the use of mirtazapine?
Be aware of signs of infection such as sore throat and seek urgent medical care if they begin to experience any
164
What are the most commonly prescribed Dopamine D2-receptor antagonists
Metoclpramide
Domperidone
165
Which dopamine receptor antagonist can be used in patients with Parkinson's disease?
Domperidone
## Footnote
Domperidone does not cross the BBB
166
What are the clinnical indications for the use of dopamine receptor antagonists?
Treatment of nausea and vomiting, but particularly in the context of reduced gut motility
167
What are the important adverse effects associated with the use of metoclopramide?
- Diarrhoea
- Extrapyrimadal symptoms (oculofyric crisis)
-
168
What are the important adverse effects associated with the use of domperidone?
- Diarrhoea
- QT prolongation
169
When is the use of metoclopramide contraindicated?
- Neonate, children, and adults at increased risk of side effects
- Parkinson's disease
- GI obstruction
170
When is the use of domperidone contraindicated?
- Cardiac condution abnormalities
- Severe hepatic impairment
- GI obstruction
171
Which drugs interact with domperidone and to what effect?
- Antipsychotics - increase the risk of extrapyramidal effects
- Dopaminergic drugs used to treat Parkinson's
172
Which drugs interact with domperidone and to what effect?
- Drugs that prolong the QT interval (amiodarone, antipsychotics, fluconazole, quinine, quinolones, macrolides, SSRIs, venlafaxine)
- Enzyme inhibiting drugs (metronidazole, macrolides, omeprazole, sulfonamides, ketoconazole)
173
What is the ideal maximum duration for the use of metoclopramide?
5 days
174
What is the standard starting dose for both metoclopramide and domperidone?
10mg 8 hrly
175
Where long term use of metoclopramide is necessary, which other drug can be used in combination in an alternating regimen?
Erythromycin
176
What are the most commonly prescribed H1-receptor antagonists indicated for nausea and vomiting?
Cyclizine
Cinnarizine
Promethazine
177
Which drug class does cyclizine belong to?
H1-receptor antagonists (antihistamines)
178
What are cyclizine, cinnarizine, and promethazine indicated for?
Treatment of nausea and vomiting, particularly in the conext of motion sickness and vertigo
179
What are the important adverse effects associated with the use of antihistamines used for the treatment of nausea and vomiting?
- Drowsiness
- Anticholinergic effects such as dry mouth and throat
- Tachycardia + palpitations (IV use)
180
Is cyclizine sedating or non-sedating?
Sedating
## Footnote
It is the least sedating of the sedating antihistamines
181
Which drugs interact with cyclizine and to what effect?
- Other sedating drugs such as benzodiazepines and opioids
- Ipratropium andtiotropium - anticholinergic effects enhanced
182
What is the MHRA warning associated with the use of metoclopramide?
Risk of neurological adverse effects - restriction of dose and duration of use (August 2013)
183
What is the MHRA warning associated with the use of metoclopramide?
Lack of efficacy in children; reminder of contraindications in adults and adolescents
184
What is the minimum age of a patien who can receive domperidone?
12 years old
185
Which drug class does ondansetron belong to?
Serotonin 5-HT3-receptor antagonists
186
Which drug class does granisetron belong to?
5-HT3-receptor antagonists
187
What are the 5-HT3-receptor antagonists indicated for?
Treatment of nausea and vomiting, particularly in the context of anaesthesia and chemotherapy
188
What are the important adverse effects associated with the use of ondansetron and granisetron?
Adverse effects are rare but:
- QT prolongation
- Diarrhoea
- Constipation
- Headaches
189
What is the main warning for use associated with the 5-HT3-receptor antagonists?
QT prolongation
190
Which drugs interact with ondansetron and granisetron and to what effect?
Other drugs that prolong the QT interval such as amiodarone, fluconazole, quinine, quinolones, macrolides, SSRIs, venlafaxine, and tricyclic antidepressants
191
What is the typical starting dose of ondansetron?
4 - 8mg 12hrly
192
Can ondansetron be used to treat morning sickness?
Yes
193
What are the main constituents of co-careldopa?
Levodopa
Carbidopa
194
What are the main constituents of co-beneldopa?
Levodopa
Benserazide
195
What are the most commonly prescribed Dopamine agonist drugs?
Ropinirole
Pramipexole
196
What is levodopa indicated for?
1. Parkinson's disease
2. Management of secondary Parkinsonism
197
What are the dopamine agonists indicated for?
1. Early Parkinson's disease where they are preferred over levodopa preparations
198
What are the important adverse effects associated with the use of all dopaminergic drugs?
- Nausea
- Drowsiness
- Confusion
- Hallucinations
- Hypotension
199
Which drugs interact with dopaminergic drugs?
- 1st and 2nd generation antipsychotics
- Metoclopramide
200
Which drug is sold under the brand name Madopar?
Co-beneldopa
201
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Which drug is sold under the brand name Sinemet?
Co-careldopa
202
When should dopaminergic drugs be used with caution?
- Elderly
- Cognitive or psychiatric disease
- Hypotension
203
Name some first-genertion antipsychotics
Haloperidol
Prochlorperazine
Chlorpromazine
204
Which drug class does haloperidol beliong to?
First-generation antipsychotic
205
Which drug class does prochlorperazine belong to?
First-generation antipsychotic
206
Which drug class chlorperazine belong to?
First-generation antipsychotic
207
What are the first-generation antipsychotics indicated for?
1. Urgent treatment of psychomotor agitation
2. Schizophrenia
3. Bipolar disorder
4. Nausea and vomiting, particularly in the context of palliative care
208
What are the important adverse effects associated with the use of first-generation antipsychotics?
- Extrapyramidal effects
- Neuroleptic malignancy syndrome
- Tardive dyskinesia
- Drowsiness
- Hypotension
- QT prolongation
- Hyperprolactinaemia
209
When should first generation antipsychotics be used with caution or avoided?
- Caution in the elderly
- Avoided in dementia
- Avoided in Parkinson's
210
Which drugs interact with antipsychotics?
Interactions with first-gen antipsychotics are extensive, but the most prominent are those that extend the QT interval
211
What is the MHRA warning associtaed with the use of haloperidol?
Reminder of risks when used elderly patients for the acute treatment of delirium (December 2021)
212
List some of the second-generation antipsychotics
Quetiapine
Olanzapine
Risperidone
Clozapine
213
What are the second-generation antipsychotics indicated for?
1. Urgent treatment of psychomotor agitation
2. Bipolar disorder
3. Schizophrenia
214
What are the first-generation antipsychotics indicated for that second-generation are not?
Treatment of nausea and vomiting
## Footnote
Palliative care
215
What are the MHRA warnings associated with the use of clozapine?
- Risk of potentially fatal bowel obstruction, faecal impactation, and paralytic ileus (October 2017)
- Monitoring serum concentrations for toxicity (August 2020)
216
Which drug class does clozapine belong to?
Second-gen antipsychotics
217
What are the important adverse effects associated with the use of clozapine?
- Agranulocytosis
- Myocarditis and cardiomyopathy
- Intestinal obstruction
- QT prolongation
- Extrapyramidal effects
- Sedation
- Diabetes
218
What are the important adverse effects associated with the use of second-generation antipsychotics?
- Sedation
- Extrapyramidal effects
- QT prolongation
- Diabetes
219
When should the use of clozapine be avoided?
- Cardiovascular disease
- Neutropenia
220
When should second-generation antipsychotics be used with caution?
Cardiovascular disease
221
Concurrent use of which drugs should be avoided during the use of second-generation antipsychotics?
Dopmaine blocking antiemetics (metaclopramide and donperidone)
Drugs that prolong the QT interavl (amiodarone, other antipsychotics, quinine, quinolones, fluconazole, macrolides, SSRIs, venlafaxine)
222
What are the indications for the strong opioids?
## Footnote
Morphine and oxycodone
1. Rapid relief of acute severe pain
2. Relief of chronic pain
3. Relief of breathlessness in end of life care
4. Relief of breathlessness and anxiety in acute pulmonary oedema
223
Which drugs are used alongside morphine in the treatment of acute pulmonary oedema?
Furosemide
Oxygen
Nitrates
224
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What are the important adverse effects associated with the use of strong opioids?
- Respiartory depression
- Nausea and vomiting
- Constipation
- Pupillary constriction
- Neurological depression
- Dependence
225
When is a dose reduction required for strong opioids?
- Elderly
- Renal impairment
- Hepatic impairment
226
When is the use of morphine contraindicated?
- Respiratory depression
- Head injury
- Raised intracranial pressure
- Paralytic ileus
227
What are the MHRA warnings associated with the use of morphine?
- Risk of potentially fatal respiratory depression (March 2020)
- Risk of dependence and addiction (September 2020)
228
Concurrent use of which drugs should be avoided during treatment with morphine?
Other sedating drugs (benzodiazepines, antipsychotics, tricyclic antidepressants)
229
When is the use of oxycodone preferrable to morphine?
When morphine has **not been tolerated** and patients with **renal imapirment (eGFR < 30)**
230
The dose of morphine used for breakthrough analgesia is usually proportionate to how much of the total daily dose?
1/6
231
What are the most commonly prescribed weak opioids?
Tramadol
Codeine
Dihydrocodeine
232
What are the weak opioids indicated for?
Mild to moderate pain
233
Which drugs are on the final rung of the WHO pain ladder?
Morphine and oxycodone
234
Which drugs are on the second rung of the WHO pain ladder?
Weak opioids:
- Codeine
- Tramadol
- Dihydrocodeine
235
Which drugs are on the first rung of the WHO pain ladder?
Paracetamol
NSAIDs
236
What are the important adverse effects associated with the use of weak opioids?
- Respiratory depression (overdose)
- Neurological depression (overdose)
- Constipation
- Nausea and vomiting
237
Can codeine and dihydrocodeine be given intravenously?
No, this results in an anaphylaxis-like reaction
238
Which opioid is associated with lowering the seizure threshold?
Tramadol
239
When do the weak opioids need to be used with caution?
- Elderly
- Renal impairment
- Hepatic impairment
240
Which drugs interact with the tramadol and to what effect?
- Other sedating medication (benzodiazepines, antipsychotics, tricyclic antidepressants)
- Drugs that lower the seizure threshold (antipsychotics)
- Other serotoniergic drugs such as SSRIs and tricyclic antidepressants - increased risk of serotonin syndrome
241
What are the clinical indications for the use of paracetamol?
1. First-line for acute and chronic pain
2. Fever and its associated symptoms
242
When should paracetamol be used with caution?
In those at an increased risk of liver toxicity
243
Which drugs interact with paracetamol and to what effect?
Paracetamol has very few clinically significant interactions.
CYP inducing drugs do however increase the risk of liver toxicity **after overdose**
244
What is the typical dose of paracetamol for every route?
0.5 - 1grams
4 - 6hrly (Max 4g daily)
245
What is the antidote for paracetamol overdose?
N-acetylcysteine
246
When is the use of lithium contraindicated?
- LLow sodium diet
- Addison's disease
- Cardiac disease
- Dehydration
247
Can lithium be used in pregnancy and breastfeeding?
Pregnancy - Avoid in 1st trimester / can be used in 2nd and 3rd but requires dose adjusting
Breastfeeding - Avoid
248
What adverse effects are associated with the long-term use of lithium?
- Thyroid disorders
- Memory impairment
- Mild cognitive impairment
249
What are the important adverse effects associated with the use of lithium?
- QT prolongation
- Arrythmias
- Atroventricular block
- Cardiomyopathy
- Hyperglycaemia
250
What are the signs and symptoms of lithium overdose?
- GI disturbances
- Muscle weakness
- Tremor
- Abnormal reflexes
- Hypernatraemia
- Arrythmias and heartblock
- Renal failure
- Coma
- Death
251
What are the monitoring requirements during the use of lithium?
- Serum concentrations should be measured 12 hours after each dose
- Maintenance therapy - target range of 0.4 - 1 mmol/L
- Acute management of manic episodes - target range of 0.8 - 1 mmol/L
252
What are the key points when counselling a patient on the use of lithium?
- Be aware of the signs and symptoms of toxicity such as hypothyroidism, renal dysfuntion, and benign intracranial hypertension
- Information about lithium information pack, including alert card and serum tracking book
253
Which drug class is the first line option in depression?
SSRIs
254
Hyponatraemia is more commonly associated with which class of antidepressants?
SSRIs
255
What are the treatment options available when a patient does not respond to an SSRI?
- Increase in dose, change to another SSRI, or switching to mirtazapine
- Second-line choices include lofepramine, moclobemide, and reboxetine
- Tricyclic antidepressants or venlafaxine should only be used in severe depression
- MAOIs should only be initiated by specialists
256
What are the signs and symptoms of serotonin syndrome?
1. Neuromuscular hyperactivity
2. Autonomic dysfunction
3. Altered mental state
257
Which drug class does duloxetine?
SNRIs
258
Name the irreversible MAOIs
- Isocarboxazid
- Phenelzine
- Tranylcypromine
259
Name the reversible MAOI
Moclobemide
260
How long after treatment with MAOIs needs to be taken before starting any other antidepressants?
2 weeks
261
What is the MHRA warning associated with the use of SSRIs and SNRIs?
Small increased risk of postpartum haemorrhage when used in the month before delivery (January 2021)
262
Which side effects are associated with the use of all antipsychotic medications?
- Hyperprolactinaemia
- Cardiovascular effects
- Sexual dysfunction
- Hypotension
- Hyperglycaemia and diabetes
- Weight gain
- Neuroleptic malignant syndrome
263
How should a patient with Parkinson's disease be switched from one levodopa/dopa-decarboxylase inhibitor preparation (co-careldopa) to another (co-beneldopa)?
The previous levodopa formulation needs to be discontinued for at least 12 hourd be starting the next preparation
264
When switching a patient from MR levodopa to dispersible co-beneldopa what should happen to the dosage?
Dose of dispersible co-beneldopa should be 30% less than the previous levodopa formulation
265
Which drugs are available for the treatment of post-operative nausea and vomiting?
A combination of 2x antiemetics that have different mechanisms of action:
- Serotonin receptor antagonists (ondansetron + granisetron)
- Dexamethasone
- Haloperidol
- Cyclizine
- Prochlorperazine
266
What age and above is the use of cyclizine licensed in?
6 years old and older
267
What is the MHRA warning associated with the use of ondansetron?
Small increased risk of oral clefts following use in the first 12 weeks of pregnancy
268
What is the special hazard regarding aspirin and warfarin?
Concurrent use of the two together increases bleed risk by 1.5 to 2 times without offering any clinical benefit for stroke or cardiovascular events
269
How often do fentanyl patches need to be changed?
72 hours
270
What schedule of drug is Tramadol?
Schedule 3
271
A MAOI should not be started until:
- At least 2 weeks since a previous MAOI has been stopped
- At least 1 or 2 weeks since tricyclic has been stopped (3 weeks for clomipiramine and imipramine)
- At least 1 week since SSRI has been stopped (5 weeks in the case of fluoxetine)
272
When is the use of naproxen contraindicated?
Heart failure
273
What strength of paracetamol should be dispensed when the prescription is for a paediatric oral mixture or suspension?
120mg/5ml
274
What is the paracetamol dosing for a child of **1 - 2** months of age?
**30 - 60mg 8hrly PRN (Max 60mg/kg/day)**
275
What is the paracetamol dosing for a child of **3 - 5** months of age?
**60mg** every 4 - 6hrs (Max QD)
276
What is the paracetamol dosing for a child of **6 - 23** months of age?
**120mg** every 4 - 6hrs (Max QD)
277
What is the paracetamol dosing for a child of **2 - 3** years of age?
**180mg** every 4 - 6hrs (Max QD)
278
What is the paracetamol dosing for a child of **4 - 5** years of age?
**240mg** every 4 - 6 hrs (Max QD)
279
What is the paracetamol dosing for a child of **6 - 7** years of age?
**240mg - 250mg** every 4 - 6hrs (Max QD)
280
What is the paracetamol dosing for a child of **8 - 9** years of age?
**360mg - 375mg** every 4 - 6hrs (Max QD)
281
What is the paracetamol dosing for a child of **10 - 11** years of age?
**480mg - 500mg** every 4 - 6hrs (Max QD)
282
What is the paracetamol dosing for a child of **12 - 15** years of age?
**480mg - 750mg** every 4 - 6hrs (Max QD)
283
What is the paracetamol dosing for a child of **16 - 17** years of age?
**500mg - 1000mg** every 4 - 6hrs (Max QD)
284
What schedule of drug is buprenorphine?
Schedule 3
285
What is the MHRA warning associated with the use of codeine?
Restricted use in children due to reports of morphine toxicity (July 2013)
286
What schedule of drug is codeine?
Schedule 5
287
What are the MHRA warnings associated with the use of fentanyl?
- Life-threatening exposure and fatal opioid toxicity from accidental exposure, particularly in children (October 2018)
- Transdermal fentanyl patches for non-cancer pain: Do not use in opioid naive patients (September 2020)
288
What schedule of drug is fentanyl?
Schedule 2
289
What is a typical dose of morphine for the management of acute or chronic pain?
5 -10mg every 4hrs
290
What schedule of drug is morphine?
Schedule 2
291
What schedule of drug is oxycodone?
Schedule 2
292
What schedule drug is pethidine?
Schedule 2
293
What schedule drug is tapentadol?
Schedule 2
294
What is the MHRA warning associated with the use of tapentadol (PALEXIA)?
Risk of seizures and reports of serotonin syndrome when co-administered with other medicines (January 2019)
295
When should tapentadol be used with caution?
Epilepsy
Concurrent use with other drugs that lower seizure threshold (SSRIs, tricyclics, antpsychotics)
Other serontinergic medicines (SSRIs, tricyclics, antipsychotics)
296
What are the first line options for the treatment of acute migraine?
Aspirin
Ibuprofen
serotonin receptor agonists ('triptans')
297
What are the treatment options for migraine in patients presenting with vomiting?
SC sumatriptan
Nasal zolmitriptan
Diclofenca sodium
298
What is the recommended treatment option for patients in whom monotherapy has been unsuccessful for the treatment of migraine?
Sumatriptan and naproxen
299
Which antiemetics can be used for the treatment of migraine / N+V in migraine?
Metoclopramide
Prochlorperazine
Domperidone (where metoclopramide not tolerated)
300
What is the first line option for the prophylaxis of episodic or chronic migraines?
Propranolol
301
What is the second line option for the prophylaxis of episodic or chronic migraines where beta-blockers have been unsuccessful or are not appropriate?
Topiramte
302
What are the options for prophylaxis of mentrual migraines?
Frovatriptan
Zolmitriptan
Naratriptan
303
When is the use of sumatriptan contraindicated?
- Ischaemic heart disease
- Hypertension
- Peripheral vascular disease
- Myocardial infarction
- Coronary vasospasm
304
Is sumatriptan available over the counter?
No, it is a POM
305
What drug is given for trigeminal neuralgia?
Carbemazepine
306
What are the first line options for the treatment of neuropathic pain?
Amitriptyline / Nortriptyline
Pregabalin / Gabapentin
## Footnote
Nortriptyline is unlicensed for the treatment of neuropathic pain
307
When and for how long can benzodiazepines be used for the treatment of anxiety an insomnia?
When either is severe or disabling
4 weeks maximum duration
## Footnote
Use for 'mild' anxiety is unacceptable
308
When should the Z-drugs be prescribed in caution and when should their use be avoided?
- Caution in the elderly
- Avoid in obstructive sleep apnoea
- Avoid in respiratory muscle weakness
- Avoid in respiratory depression
309
Which drugs interact with the zopiclone and zolpidem and to what effect?
- Antihistamines - enhanced sedative effects
- Benzodiazepines - enhanced sedative effects
- Antihypertensives - enhanced hypotensive effects
- CYP inhibitors - enhanced sedation
- CYP inducers - decreased sedation/efficacy
310
What are the typical doses for zopiclone and zolpidem?
Zopiclone - 7.5mg ON
Zolpidem - 10mg ON
## Footnote
Doses should be halved in the elderly
311
Use of Z-drugs is not recommended past what duration?
4 weeks, as dependence/withdrawal can develop
312
What action needs to be taken if a patient has missed 3 days of their regular prescribed opioid maintenance therapy?
Dose might need to be reduced due to decreased tolerance
313
What schedule of drug is methadone?
Schedule 2
314
What is the main cardiac-associated warning with the use of methadone?
Risk of QT prolongation
315
What schedule of CD is midazolam
Schedule 3
316
What schedule of CD is temazepam?
Schedule 3
317
What schedule of CD is gabapentin?
Schedule 3
318
What schedule of CD is pregabalin?
Schedule 3
319
What schedule of CD is zopiclone?
Schedule 4
320
How long are invoices for POMs on a private prescription retained for?
2 years
320
What schedule of CD is zolpidem?
Schedule 4
321
What are the two sub groups of Schedule 4 CDs?
Sch 4.i (CD BENZ POM)
Sch 4.ii (CD ANAB POM)
322
What are the most commonly prescribed NSAIDs?
- Ibuprofen
- Aspirin
- Naproxen
- Diclofenac
- Etoricoxib
323
What are the clinical indications for the use of NSAIDs?
1. Mild to moderate pain as monotherapy or adjunct with paracetamol
2. Treatment of pain associated with inflammation (rheumatoid arthritis, severe osteoarthritis, and acute gout)
324
What are the important adverse effects associated with the use of NSAIDs?
- GI toxicity
- Renal impairment
- Cardiovascular events (MI/stroke)
- Bronchospasm
- Angioedema
- Fluid retention
325
When do NSAIDs need to be used with caution?
- History of peptic ulcer
- Historyof GI bleed
- Cardiovascular disease
- Renal impairment
326
When should the use of NSAIDs be avoided?
- Severe renal impairment
- Heart failure
- Renal impairment
- Known NSAID hypersensitivity
327
Which drugs interact with NSAIDs and to what effect?
- Aspirin - increased risk of peptic ulceration
- Corticosteroids - increased risk of peptic ulceration
- SSRIs - increased bleeding risk
- Venlafaxine - increased bleeding risk
- Anticoagulants - increased bleeding risk
- ACEIs - increased risk of renal impairment
- Diuretics - increased risk of renal impairment
- Antihypertensives - decreased efficacy of most antihypertensives
328
What is commonly prescribed alongside NSAIDs?
PPI
329
What is the dosing of ibuprofen in childen **1 -2 months** of age?
5mg/kg 3 - 4 times day
330
What is the dosing of ibuprofen in childen **3 -5 months** of age?
50mg TDS (Max 30mg/kg/day)
331
What is the dosing of ibuprofen in childen **6 -11 months** of age?
50mg TDS - QD (Max 30mg/kg/day)
332
What is the dosing of ibuprofen in childen **1 - 3 years** of age?
100mg TDS (Max 30mg/kg/day)
333
What is the dosing of ibuprofen in childen **4 - 6 years** of age?
150mg TDS (Max 30mg/kg/day)
334
What is the dosing of ibuprofen in childen **7 - 9 years** of age?
200mg TDS (Max 30mg/kg/day OR 2.4g/day)
335
What is the dosing of ibuprofen in childen **10 - 11 years** of age?
300mg TDS (Max 30mg/kg/day OR 2.4g/day)
336
What is the dosing of ibuprofen in childen **12 - 17 years** of age?
Initially 300 - 400mg TDS - QD
Maintenance of 200 - 400mg TDS
(Max 600mg QD)
337
What is the MHRA warning asssociated with the use of ibuprofen?
Potential risks following prolonged use after 20 weeks of pregancy (June 2023)
338
Is ibuprofen safe in pregnancy and breastfeeding?
- It should be avoided in the first and second trimesters of pregnancy
- It is safe in breastfeeding
339
What needs to be monitored during the use of clozapine?
Neutrophils and leukocytes
