Neuro/Psych/Rheumatology drug SE

Question 1

9 Valproate?

Interaction?

Answer 1

Alopecia
Encephalitis
Liver failure/Pancreatitis
Weight gain
Tremor
Thrombocytopaenia
Teratogenic
Oedema
Ataxia

Interaction - P450 inhibitor

Question 2

4 Lamotrigine?

Breastfeeding?

Answer 2

Rash
Steven Johnson syndrome
Tremor
Agitation

Avoid in breastfeeding - risk of SJS in kid

Question 3

5 Carbamazepine?

Interaction?

Answer 3

Worsening of generalised epilepsy
Leucopaenia
Drowsiness
Double vision
Impaired balance

Interaction - P450 inducer

Question 4

1 Levetiracetam?

Answer 4

Depression/mood swings

Question 5

3 Topiramate?

Answer 5

Sedation
Dysphasia
Weight loss

Question 6

Phenytoin - 6 chronic SE?

Interaction

Answer 6

Gingival hyperplasia
Hirsutism
Megaloblastic anaemia
Osteomalacia
Lymphadenopathy
Aplastic anaemia

Interaction - P450 inducer

Question 7

Phenytoin - 5 acute toxicity?

Answer 7

Cerebellar signs - confusion, drowsy, ataxia, nystagmus, slurred speech

Question 8

Lithium - 7 chronic SE?

Drugs to avoid?

Answer 8

Fine tremor
Metallic taste/dry mouth
Weight gain
Hypothyroidism
QT prolongation
Renal function decline - diabetes insipidus
Teratogenic - Ebstein's anomaly

Avoid: ACEI, NSAIDs, Diuretics

Question 9

Lithium - 5 toxicity?

Answer 9

D&V
Coarse tremor
Myoclonus
Confusion & drowsiness
Kidney failure

Question 10

General SSRI?

Answer 10

GI upset
Vivid dreams
GI bleeding - give with PPI, avoid NSAIDs
Sexual dysfunction
Transient worsening of symptoms
Hyponatraemia in elderly

Question 11

TCA?

Answer 11

Sedation
Weight gain
QT prolongation
Postural hypotension
Dry mouth, urinary retention, blurred vision etc

Question 12

MOAI? (4)
What to avoid with?
Reversible and Irreversible?

Answer 12

Hypertensive crisis if have cheese, red wine, game meat
(Rx: phentolamine infusion)

Also anticholinergic effects, seizures and hepatic impairment

Avoid with other antidepressants/sedatives e.g. barbiturates (P450 inhibitor - potentiates them)

Reversible - Moclobemide (less SE but less effective)
Irreversible - Phenelzine

Question 13

Mirtazapine?

Answer 13

Weight gain
Sedation (caution with other sedatives)

Rarely, blood dyscrasias or seizures

Question 14

Trazodone:

• MOA
• Use?

Answer 14

SARI - Serotonin/NA reuptake inhibitor and antagonist

Can be used to augment SSRI

Question 15

Typical antipsychotics?

Answer 15

EPSE:

• Acute dystonia (procyclidine)
• Akathisia (propranolol)
• Parkinsonism (levodopa/stop drug)
• Tardive dyskinesia (tetrabenazine symptomatically)

Question 16

Atypical antipsychotics:

Answer 16

Metabolic syndrome - insulin resistance/high BP, obesity, high cholesterol
Drowsiness
Hyperprolactinaemia
Sexual dysfunction
Risk of stroke in elderly

Question 17

Clozapine?

Answer 17

Agranulocytosis (bloods weekly for 6 months, then 2 weekly for 6 months, then 4 weekly)
Myocarditis (ECG 3 monthly)

Question 18

Aripiprazole?

Answer 18

Postural hypotension
Constipation
Headache

Question 19

What SSRI is:

• safest in cardiac problems?
• safest in epilepsy?
• assoc w QTc prolongation?
• more alerting?
• assoc w anticholinergic SE? (e.g. drowsiness)
• used post-MI?

Answer 19

safe in cardiac - sertraline

safe in epilepsy - citalopram

assoc w QTc prolongation - citalopram

more alerting - fluoxetine

anticholinergic - paroxetine (drowsiness)

post-MI - sertraline

Question 20

Who to avoid TCA in? (4)

Answer 20

Recent MI or cardiac problems
Older people
Suicidal ideation (cardiotoxic)
Mania

Question 21

Antidepressant best for atypical depression?

Answer 21

MAOI

Question 22

Indications for ECT?

Answer 22

Depression:

• life-threatening poor fluid intake
• strong suicidal ideation
• psychotic features
• antidepressants not working

Established Mania

Schizophrenia:

• catatonia
• positive psychotic symptoms
• schizoaffective disorder

Question 23

SE of ECT?

Answer 23

Memory loss

Confusion, headache, nausea, muscle pain

Question 24

ECG changes that can occur with:

• TCA?
• Lithium?

Answer 24

TCA - QT prolongation, ST elevation

Lithium - T-wave flattening/inversion

Question 25

Monitoring of Lithium? | prior, initiation, 3 monthly, 6 monthly

Answer 25

Prior: U&E, TFT, ECG Initiation: Li level 12 hour post-dose and every 5 days until level stable 3 monthly: Li and U&E 6 monthly: TFT

Question 26

What to check prior to initiation of valproate?

Answer 26

PLT count | LFT

Question 27

What receptors does Clozapine work on?

Answer 27

5-HT2 | D4

Question 28

Effects of anti-psychotics blocking: - alpha-adrenergic receptors? - cholinergic? - Histamine? - 5HT2c?

Answer 28

postural hypotension Dry mouth, blurred vision, constipation, urinary retention Sedation & weight gain Weight gain (mainly Olanzapine and Clozapine)

Question 29

What antipsychotics are most likely to cause weight gain?

Answer 29

Olanzapine Clozapine (due to 5-HT2c blockade)

Question 30

What antipsychotic is most likely to cause: - QT prolongation? - EPSE/neuroleptic malignant syndrome? - blue-grey discolouration?

Answer 30

QT - Haloperidol EPSE/Neuro mal - Typicals Blue-grey - chlorpromazine

Question 31

Within atypical psychotics, what drugs does EPSE happen in higher doses?

Answer 31

Risperidone, olanzapine | uncommon with aripiprazole, rare with clozapine

Question 32

What antipsychotic to use for: - avoidance of EPSE? - least sedating? - most sedating? - avoid weight gain? - treatment-resistant? - depot? (poor compliance)

Answer 32

avoid EPSE - atypicals least sedating - Haloperidol, Risperidone Most sedating - Olanzapine, Chlorpromazine Avoid weight gain - Aripiprazole, Haloperidol Treatment-resistant - Clozapine Depot - Risperidone

Question 33

Methotrexate SE? (4)

Answer 33

Pulmonary fibrosis Liver cirrhosis Teratogenic Marrow suppression

Question 34

Prednisolone SE? (8)

Answer 34

``` Osteoporosis impaired glucose tolerance hypertension cushingoid features adrenal suppression AVN femoral head immunosuppression glaucoma/cataracts ```

Question 35

Anti-TNF drugs? Etanercept? Infliximab?

Answer 35

TB reactivation Etanercept - demyelination Infliximab - given IV

Question 36

Sulfasalazine?(1)

Answer 36

reduced sperm

Question 37

hydroxychloroquine?(1)

Answer 37

Irreversible retinopathy | Corneal deposits

Question 38

leflunomide? (1)

Answer 38

interstitial lung disease

Question 39

IM gold? (2)

Answer 39

proteinuria | peripheral neuropathy

Question 40

Penicillamine? (5)

Answer 40

``` Rash myasthenia syndrome goodpastures proteinuria anaemia ```

Question 41

Azathioprine? (1)

Answer 41

Marrow suppression (aka myelosuppression)

Question 42

Which rheumatoid drugs are teratogenic?

Answer 42

Methotrexate - both male and female stop 3 months before pregnancy Leflunomide