1
Q
What are the symptoms of dementia?
A
Memory loss
Difficult thinking
Psychiatric/behavioural problems
Language issues
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2
Q
What are the 3 acetylcholinesterase inhibitors used for mild-moderate alzheimers disease?
A
- Donepezil
- Galantamine
- Rivastigmine
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3
Q
Which acetylcholinesterase should be stopped at the firsts sign of a skin rash (SJS)?
A
Galantamine
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4
Q
Which drug is used in moderate-severe alzheimers disease?
A
Memantine
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5
Q
What are some examples of cholinergic side effects?
A
Remember DUMB BELLS
Diarrhoea
Urination
Muscle weakness
Broncho-spasms
Bradycardia
Emesis
Lacrimation
Salivation/sweating
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6
Q
What is there an increased risk of when patients with dementia are given antipsychotics?
A
Increased risk of stroke and death
Must be started on a low dose and titrated upwards
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7
Q
Which antipsychotics are recommended in dementia patients?
A
IM haloperidol, or risperidone
Olanzapine
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8
Q
Which anti-epileptics have a long half life, and are hence given ONCE a day?
A
Phenytoin
Lamotrigine
Perampanel
Phenobarbital
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9
Q
What are the 1st and 2nd line drug treatments for focal (partial seizures)?
A
1st: lamotrigine or levetiracetam
2nd: carbamazepine
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10
Q
What are the 1st and 2nd line treatment options for tonic-clonic seizures?
A
1st: valproate
2nd: lamotrigine, levetiracetam
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11
Q
What are the 1st and 2nd line treatment options for absence seizures?
A
1st: ethosuximide or valproate
2nd: lamotrigine
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12
Q
What are the category 1 anti-epileptic drugs, and what does this mean?
A
Remember CP3
Carbamazepine, phenytoin, phenobarbital, primidone
These must be prescribed by brand and are not interchangeable
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13
Q
What are the category 2 anti-epileptic drugs, and what does this mean?
A
Remember TVLC
Topiramate
Valproate
Lamotrigine
Clonazepam
These can be switched between them, based on patient needs and clinical judgement
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14
Q
What are the category 3 anti-epileptic drugs, and what does this mean?
A
Remember GLP
Gabapentin
Levetiracetam
Pregabalin
These are not necessary to be prescribed by brand
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15
Q
What can sudden withdrawal of anti-epileptic drugs cause?
A
Severe rebound seizures
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16
Q
How long should epileptic patients not drive for if they have had an unprovoked or single isolated seizure?
A
6 months
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17
Q
How long should patients wait till they can drive again once they have been initially diagnosed?
A
1 year
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18
Q
Which category of anti-epileptics can cause the highest risk of teratogenicity?
A
Category 1
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19
Q
Which anti-epileptic can cause cleft palate in the first trimester?
A
Topiramate
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20
Q
Which anti-epileptic drugs are enzyme inducing, and hence effective contraception is needed?
A
(Remember CRAPPSS)
Carbamazepine
Phenytoin
Phenobarbital
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21
Q
Why are newborns given a vitamin K injection once they are born?
A
To reduce the risk of neonatal haemorrhage
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22
Q
Which anti-epileptic drugs are present in high amount in breast milk?
A
Remember ZELP
Zosinamide
Ethosuximide
Lamotrigine
Primidone
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23
Q
Which 2 anti-epileptic drugs are at risk of accumulating in an infant if a mother is breastfeeding, and why?
A
Phenytoin and lamotrigine, because the infants metabolism is slower
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24
Q
What are the symptoms of hypersensitivity syndrome associated with category 1 anti-epileptics within the first 1-8 weeks of starting treatment?
A
Rash
Fever
Lymphadenopathy
Systemic side effects
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25
Q
Which specific side effect should patients report if they are on any anti-epileptic?
A
Must report signs of suicidal behaviour/thought, or mood changes
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26
Q
Which anti-epileptic medications need to be reported if signs of infection/blood dyscrasias/bruising/bleeding occurs?
A
Remember C VET PLS
Carbamazepine
Valproate
Ethosuximide
Topiramate
Phenytoin
Lamotrigine
Zonisamide
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27
Q
Why should patients report signs of raised intra-ocular pressure with topiramate?
A
Because there is a risk of acute-closure glaucoma associated with topiramate
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28
Q
Which specific side effect are patients taking gabapentin mostly at risk of?
A
Risk of severe respiratory depression
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29
Q
Which anti-epileptic is an enzyme inhibitor?
A
Sodium valproate
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30
Q
What is the mechanism of action of phenytoin?
A
Binds to neuronal sodium channels and prolongs inactivity
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31
Q
What is the therapeutic plasma range of phenytoin?
A
10-20mg/L
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32
Q
Which form of phenytoin is its active form?
A
Free phenytoin (not when it is protein bound)
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33
Q
Why should clinicians monitor protein concentrations in a patient taking phenytoin?
A
Because phenytoin is highly protein bound, so patients with hypoalbuminaemia must be cautioned with as they have a risk of toxicity
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34
Q
What are the symptoms of phenytoin toxicity?
A
Remember SNAtCHED
Slurred speech
Nystagmus (eye rolling)
Ataxia (lack of muscle co-ordination)
Confusion
Hyperglycaemia
Diplopia (blurred vision)
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35
Q
Which form of phenytoin contains phenytoin sodium, and phenytoin base?
A
Tablets: phenytoin sodium
Liquid: phenytoin base
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36
Q
What are some side effects of phenytoin?
A
Coarsening of facial features
Acne
Gingivial hyperplasia
Rash (REPORT)
Infection/unexplained bruising (REPORT)
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37
Q
What are some symptoms associated with phenytoin induced hepato-toxicity?
A
Dark urine
Abdominal pain
Jaundice
Itchy skin
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38
Q
What parameters should be measured with phenytoin?
A
FBC
LFTs
ECG
BP
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39
Q
What is fosphenytoin and how is it given?
A
It is a prodrug of phenytoin which can be rapidly given IV or IM and has fewer site reactions compared to phenytoin
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40
Q
Which drugs can lower the seizure threshold when given with phenytoin?
A
TCAs
Tramadol
Quinolones
Mefloquine
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41
Q
What is the therapeutic range of carbamazepine and when are plasma levels measured?
A
4-12mg/L, measured 1-2 weeks after 1st dose
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42
Q
What are the symptoms of carbamazepine toxicity?
A
Inco-ordination
Ataxia
Nystagmus
Arrhythmia
Blurred vision
GI sid effects
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43
Q
What is their an increased risk of if carbamazepine is given with e.g. SSRIs, diuretics, NSAIDs or TCAs?
A
Hyponatraemia
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44
Q
How long is a prescription for sodium valproate valid for, and what is the max days of supply?
A
Prescription is valid for 7 days, and a max. of a 30 day supply is legally allowed.
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45
Q
What are examples of a highly effective contraception method as part of the PPP?
A
Either a copper IUD/sterilization, or use of 2 other forms e.g. barrier + pill
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46
Q
What symptoms should patients on sodium valproate report immediately?
A
Hepatotoxicity signs
Blood dyscrasias
Pancreatitis
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47
Q
What is status epilepticus and how is it managed?
A
It is a compete loss of consciousness + seizure lasting for >5 minutes.
Iv lorazepam is given
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48
Q
Which 2 benzodiazepines are short-acting?
A
Lorazepam and oxazepam
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49
Q
Which drugs are used to help with anxiety?
A
Benzodiazepines
Beta-blockers for e.g. palpitations
Buspirone
TCAS
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50
Q
How do benzodiazepines work?
A
They work by enhancing the binding of GABA to their receptors, hence increasing depressant/inhibitory effects
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51
Q
What are some side effects of benzodiazepines?
A
Hostility aggression
Overdose risk (resp. depression, coma)
Sedation
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52
Q
How should benzodiazepines be gradually withdrawn?
A
Equivalent dose of diazepam should be converted and titrated over.
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53
Q
What are the 1st and 2nd treatment options for ADHD?
A
1st: methylphenidate
2nd: lisdexamfetamine
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54
Q
What schedule drug is methylphenidate?
A
CD2
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55
Q
What are some side effects of methylphenidate?
A
Weight loss
Increased HR/BP
Growth restriction i children
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56
Q
Which condition is contraindicated for the use of most CD2 drugs?
A
CVD
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57
Q
What side effects can atomoxetine cause?
A
Suicidal ideation
Hepatotoxicity
QT prolongation
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58
Q
Which drugs are used to treat an acute episode of bipolar disorder?
A
Benzodiazepines
Antipsychotics - QOR (quetiapine, olanzapine, risperidone)
Haloperidol
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59
Q
What is the therapeutic range for lithium? What about during an acute manic episode?
A
0.4-1mmol/L normally
0.8-1mmol/L during an acute manic episode
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60
Q
How often should lithium plasma levels be measured?
A
12h after first dose or 1 week after dose changes, every 3 months for the 1st year, then every 6 months thereafter
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61
Q
What monitoring is required if a patient is taking lithium?
A
Renal function
TFTs
BMI
ECG
FBC
Electrolytes (esp. Na+)
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62
Q
What are the symptoms of lithium toxicity?
A
Renal impairment
Visual disturbances
CNS disturbances
GI side effects
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63
Q
What are some counselling points that should be mentioned to a patient taking lithium?
A
Report signs of hypothyroidism
Report signs of renal dysfunction
Report signs of benign intracranial hypertension
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64
Q
What can hyponatraemia cause in a patient taking lithium?
A
Can cause lithium toxicity
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65
Q
What should you always tell a patient who is taking lithium in terms of fluid and electrolytes?
A
Must maintain adequate salt/water intake, to avoid products with electrolytes e.g. dioralyte, and to always carry lithium alert card
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66
Q
Which drugs can prolong QT interval?
A
Amiodarone
Lithium
Quinolones
Macrolides
SSRIs
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67
Q
Why is imipramine avoided in patients with dementia?
A
Because it has the most anticholinergic properties
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68
Q
Why is fluoxetine recommended in younger people?
A
Because there is less risk for suicide
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69
Q
How long so SSRIs usually take to work?
A
At least 2 weeks
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70
Q
Why are MAO inhibitors rarely used for depression?
A
Because they have dangerous food/drug interactions
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71
Q
Which SSRI is safest to use in CVD patients?
A
Sertraline
72
Q
What are some side effects of SSRIs?
A
Hyponatraemia
Suicidal ideation
Serotonin syndrome
73
Q
How long should you wait before switching between different SSRIs?
A
Usually 1 week
(2 weeks if switching to sertraline, or 5 weeks for fluoxetine)
74
Q
Over how many weeks should any antidepressant dose be reduced?
A
Dose should be reduced gradually over 4 weeks
75
Q
Which 2 antidepressants have the highest risk of withdrawal reactions?
A
Paroxetine
Venlafaxine
76
Q
Which 2 SSRIs cause QT prolongation?
A
Citalopram
Escitalopram
77
Q
Which 2 neurotransmitters do TCAs inhibit the reuptake of?
A
5-HT (serotonin) and NA (noradrenaline)
78
Q
What are some side effects of SSRIs?
A
Bleeding
QT interval prolongation
Lowered seizure threshold
Serotonin syndrome in high doses
79
Q
What is the usual dose of TCAs?
A
Once daily at bedtime
80
Q
What are some side effects of TCAs?
A
CV side effects e.g. QT prolongation, arrythmia
Antimuscarinic side effects
Seizures
Hypotension
81
Q
Which MAO inhibitor has the most risk of causing hepatotoxicity?
A
Phenelzine
82
Q
What other side effects are involved with the use of MAO inhibitors?
A
Postural hypotension
Hypertensive crisis - throbbing headaches
Hepatotoxicity
83
Q
Which foods should people taking MAO inhibitors avoid?
A
Tyramine containing foods, e.g.
Mature cheese
Red wine
Game
Pickled herring
Alcohol
84
Q
What occurs in the brain in schizophrenic patients?
A
Overactivity of dopamine in the mesolimbic pathway causing positive symptoms, and under-activity of the mesocortical pathway causing negative symptoms
85
Q
Why should you avoid prescribing more than 1 antipsychotic in schizophrenic patients?
A
Because there is an increased risk of EPSE, CV events, and QT prolongation risk
86
Q
Which 2nd generation antipsychotic is prescribed if >2 antipsychotics have not worked?
A
Clozapine
87
Q
What type of antipsychotics are given during an acute emergency? What are some examples of these?
A
Short acting IM injections to induce rapid tranquillisation
Can include olanzapine, haloperidol, or zuclopenthixol
88
Q
What should you do to the dose of anti-psychotics in elderly patients?
A
Reduce the adult dose by half
89
Q
How often should antipsychotics be reviewed if used in a dementia patient?
A
At least every 6 weeks
90
Q
What are 1st generation antipsychotics also known as?
A
Typicals
91
Q
What side effects are associated with the use of 1st generation antipsychotics?
A
Extra pyramidal side effects
Hyperprolactinaemia
92
Q
What are some examples of 1st generation antipsychotics?
A
Haloperidol
Chlorpromazine
Prochlorperazine
Flupentixol
93
Q
Which 2 antipsychotics are most associated with QT prolongation?
A
Haloperidol
Quetiapine
94
Q
What are 2nd generation antipsychotics also known as?
A
Atypicals
95
Q
Which 2 2nd generation antipsychotics are most associated with hyperprolactinaemia?
A
Amisulpride
Risperidone
96
Q
Which antipsychotic is not associated with hyperprolactinaemia?
A
Aripiprazole
97
Q
Which 2 2nd generation antipsychotics are most associated with the most weight gain and diabetes?
A
Olanzapine
Clozapine
98
Q
Why does hyperprolactinaemia occur with antipsychotics?
A
Because dopamine is associated with prolactin inhibition. Antipsychotics work by decreasing dopamine in the brain, hence causing high levels of prolactin
99
Q
What is the 48h rule associated with clozapine?
A
If >2 doses of clozapine have been missed, then patient must go back to the GP to have their dose retitrated
100
Q
What are patients taking clozapine most at risk of?
A
Agranulocytosis
Severe constipation/faecal impaction
Patients must report if one or both of these occur
101
Q
What should you do to the dose of clozapine if the patient is a smoker?
A
Dose of clozapine needs to be higher as smoking is enzyme inducing
102
Q
What monitoring is required with clozapine?
A
FBC/WBCs
Weight/BMI
LFTs
HbA1c
Lipid profile
Pulse/BP
Prolactin levels
Renal function
ECG
103
Q
How often are depot antipsychotic injections given?
A
Every 1-4 weeks
104
Q
Which antipsychotics can be given as a depot injection?
A
Paliperidone
Flupentixol
Zuclopentixol
Haloperidol
105
Q
What should patients with schizophrenia have each year?
A
Physical health monitoring which includes a CVD risk assessment
106
Q
What symptoms are involved in extra pyramidal side effects?
A
Parkinsons
Dystonia
Dyskinesia
Akathisia - restlessness
Tardive dyskinesia (reversible)
107
Q
Which 2 antipsychotics are most associated with sexual dysfunction?
A
Haloperidol
Risperidone
108
Q
What happens in the brain in a parkinsons patient?
A
Dopamine deficiency in the nigrostriatal pathway, causing excessive acetylcholine in the striatum
109
Q
What are some symptoms of parkinsons disease?
A
Motor symptoms: rigidity, tremor, bradykinesia
Non-motor symptoms: dementia, depression, weight loss, speech problems
110
Q
Why should you never abruptly stop parkinsons medication?
A
Because there is a risk of acute akinesia (loss of movement) and neuroleptic malignant syndrome
111
Q
Which anti-emetic is recommended for use in Parkinsons disease?
A
Domperidone
112
Q
How does levodopa containing medications work in a Parkinsons patient?
A
It is a precursor of dopamine which crosses the BBB and converts to dopamine
113
Q
Why is levodopa sometimes given with benserazide or carbidopa?
A
To reduce peripheral breakdown of levodopa and reduce side effects like N&V
114
Q
What are some examples of ergot derived dopamine agonists? Are these recommended?
A
Bromocriptine
Cabergoline
Not recommended due to risk of fibrotic reactions
115
Q
What are some examples of non-ergot derived dopamine agonists?
A
Ropinirole
Amantadine
Rotigotine
116
Q
Which MAO-B inhibitors are sometimes used in Parkinsons disease?
A
Rasagiline
Selegiline
117
Q
What are some examples of COMT inhibitors that are used in Parkinsons disease?
A
Entacapone
Tolcapone
118
Q
Which anti-parkinsonian drugs are used if motor symptoms do not affect quality of life?
A
Levodopa
Non-ergot derived - ropinirole, amantadine, rotigotine
MAO-B inhibitors - rasagiline, selegiline
119
Q
What drug can be use din excessive drooling in Parkinsons?
A
Glycopyrronium bromide
120
Q
What colour can entacapone colour urine?
A
Brownish orange
121
Q
Which drug is used in advanced Parkinsons disease/’off’ periods? How is this given?
A
Apomorphine SC or continuous infusion
122
Q
What are the brands for levodopa + benserazide, and levodopa + carbidopa?
A
Levodopa + benserazide = co-beneldopa
Levodopa + carbidopa = co-careldopa
123
Q
Why should levodopa containing Parkinson’s drugs be taken at the same time everyday?
A
To avoid ‘off’ periods
124
Q
What are some side effects of levodopa-containing Parkinson’s drugs?
A
Impulsive behaviour - sex, gambling, eating
Excessive/sudden onset of sleep
Dyskinesia
‘Off’ periods = mobility weakness
End of dose deterioration (MR given to help with this)
125
Q
What drug is given to Parkinson’s patients for excessive sleep?
A
Modafinil
126
Q
Which drugs are unlicensed in the use of postural hypotension associated with Parkinson’s?
A
Midodrine
Fludrocortisone
127
Q
Which side effects should patients report when taking ergot derived drugs like bromocriptine, or cabergoline?
A
Dyspnoea
SOB, wheezing
Abdominal pain
These could all be signs of fibrotic reactions
128
Q
How do COMT inhibitors work?
A
They prevent the peripheral breakdown of levodopa by inhibiting the COMT enzyme, allowing more levodopa to reach the brain
129
Q
What should patients taking tolcapone (a COMT inhibitor) report?
A
Signs of hepatotoxicity
130
Q
What form of promethazine can be given in patients with persistent vomiting?
A
Buccal
131
Q
Which anti-emetics can be used in chemotherapy?
A
Dexamethasone
5-HT3 antagonists, ending in -setron
132
Q
Which anti-emetic can be used in palliative care?
A
Levomepromazine
133
Q
Which anti-emetics can be used in pregnancy?
A
Prochlorperazine
Metoclopramide
134
Q
Which anti emetic is best used in motion sickness?
A
Hyoscine bromide
135
Q
What is the max. number of days which metoclopramide can be used, and why ?
A
5 days
To reduce the risk of tardive dyskinesia and EPSE
136
Q
Why should metoclopramide not be used in over 18 years old?
A
Because there is a risk of acute dystonic reactions
137
Q
What is the max. number of days which domperidone can be used?
A
1 week
138
Q
Which side effects should patients taking domperidone immediately report?
A
Arrhythmia, syncope, palpitations
139
Q
What age should domperidone be used?
A
Over 12 years old
140
Q
Why should 5-HT3 antagonists be avoided in the 1st trimester of pregnancy?
A
Because there is a risk of cleft palate
141
Q
What is classified as chronic pain?
A
If it has been present for more than 12 weeks
142
Q
What should the dose of paracetamol be if a patient weights <50kg?
A
1g TDS
143
Q
What are the doses of paracetamol for children (up to 5 years old) of a 120mg/5ml bottle?
A
3-5 months: 60mg
6-23 months: 120mg
2-3 years old: 180mg
4-5 years old: 240mg
144
Q
What are the doses of paracetamol for children from 6+ years old from a 250/5ml bottle?
A
6-7 years old: 250mg
8-9 years old: 375mg
10-11years old: 500mg
145
Q
Why is aspirin contraindicated in children under 16 years old?
A
Because it can cause Reyes syndrome
146
Q
Which opioids are opioid agonists?
A
Heroin
Methadone
Morphine
Codeine
Fentanyl
147
Q
Which opioid is a partial agonists?
A
Buprenorphine
148
Q
Why does diamorphine have a quicker onset of action and less side effects than normal morphine?
A
Because diamorphine is water soluble, hence only small amounts are injected
149
Q
What is the rescue fractional dose of morphine?
A
1/6 - 1/10th of the total morphine daily dose
150
Q
What is the conversion from oral morphine to diamorphine?
A
Divide by 3
If from diamorphine to morphine, then x2 or x3 if severe
151
Q
Which opioid antagonist is given to reverse an acute opioid overdose?
A
Naloxone
152
Q
Which 2 laxatives are mainly given for opioid induced constipation?
A
A stimulant and osmotic
153
Q
Which specific side effect is a major concern for all opioids?
A
Respiratory depression
154
Q
What are some side effects of opioids?
A
Remember MORPHINE
Miosis (pinpoint pupils)
Out of it (sedation)
Respiratory depression
Postural hypotension
Hallucinations
Infrequency of urination
Nausea/vomiting
Euphoria
155
Q
Which opioids are the longest acting, and hence can be used as patches?
A
Buprenorphine
Fentanyl
156
Q
Why should you avoid direct heat to a fentanyl patch?
A
Because this can increase the absorption rate, leading to an increased risk of respiratory depression
157
Q
What are some examples of weak opioids?
A
Tramadol
Codeine
Dihydrocodeine
158
Q
Which genotype of patients should you avoid codeine in?
A
Ultra metabolisers or CYP2D6, because they are at risk of morphine toxicity
159
Q
What is the max daily dose of codeine for 12-18 years old?
A
240mg daily
160
Q
Why is codeine avoided in children <12 years old?
A
Because they are at more risk of respiratory side effects and morphine toxicity
161
Q
What is a patient at risk of if they take tramadol and an SSRI?
A
Serotonin syndrome
162
Q
Which specific group of drugs are used for migraines with aura, and when should they be taken?
A
5HT1 agonists (the triptans)
They must be taken at the start of the headache, not the aura
163
Q
How long after can a -triptan be repeated after taking the first dose?
A
2h after
164
Q
Which drugs can be used as prophylaxis for migraines?
A
B-blockers
Anti-epileptics
TCAs
Pizotifen
165
Q
Which anti-emetics can be used for N+V during a migraine attack?
A
Metoclopramide
Domperidone
Anitihistamines
166
Q
What drugs can be used for insomnia?
A
Z-drugs (zolpidem, zopiclone)
Benzodiazepines (diazepam, nitrazepam, temazepam)
167
Q
What is narcolepsy?
A
Long-term brain disorder that causes a person to suddenly fall asleep
168
Q
Which 2 drugs are used in assisted alcohol withdrawal?
A
Chlordiazepoxide, or diazepam
169
Q
Which benzodiazepine is used in alcohol withdrawal seizures?
A
Lorazepam
170
Q
Why must someone avoid alcohol while taking clomethiazole?
A
Because it can increase the risk of respiratory depression
171
Q
Which drugs can be given for alcohol dependence (as treatment)?
A
Acamprostate
Naltrexone
Disulfram
172
Q
What happens if a patient taking disulfram drinks alcohol?
A
Unpleasant systemic reaction, e.f. flushing N&V, tachycardia
173
Q
What causes wernickes encephalopathy?
A
Thiamine (vit. B1) deficiency
174
Q
How long should a patient avoid acidic drinks if they are taking buccal nicotine?
A
15mins after using the buccal nicotine as it can decrease the absorption rate if taken earlier
175
Q
How long does it take for methadone to reach optimal levels in the body?
A
3-10 days (it has a long half life)
176
Q
A
