Pharmaceutics Review: Dementia and Epilepsy

Flashcards for reviewing Pharmaceutics lecture notes on Dementia and Epilepsy.

What are some cognitive symptoms associated with Dementia?

1.)Memory loss

2.) difficulties thinking

3.) language problems

4.) orientation issues

What is dementia caused by

1.) Alzheimers

2.) strokes

3.) Parkinsons

What are some examples of Non-Cognitive Symptoms of Dementia?

1.) Psychiatric and behavioral problems e.g. delusions or aggression

2.) difficulties with daily activitiies

Which Acetylcholinesterase Inhibitors is used for mild-moderate alzheimers disease

1.) Rivastigmine- can cause GI disturbances

2.) Donepezil

3.) Galantamine

What’s the side effect of Galantamine

1.) can cause SJS stop if a rash is present

What are the other indications of Donepezil

1.) neuroepileptic malignant syndrome

What’s the other indication for Rivastigimine

1.) used in parkinsons

2.) can switch to patches to reduce GI effects

What’s the treatment for moderate-severe alzheimer’s disease

1.) NDMA glutamine receptor anatgonsist

2.) e.g. Memantine

What’s the pneumonic for common cholinergic side effects? (DUMBBELLS)

Diarrhea

Urination

Muscle Weakness/Cramps, Miosis

Bronchospasm

Bradycardia

Emesis

Lacrimation

Salivation/Sweating

How to manage non-cognitive symptoms of dementia

1.) antipyschotic drugs

What’s the treament for extreme violence, agression and extreme agitation

1.) oral benzodiazepene or antipsychotic

2.) if IM use Halopiderol, Olanzapine or Lorazepam

What does the MHRA advice (2009) state regarding antipsychotic drugs and dementia?

antipsychotics in elderly patients with dementia leads to a higher risk of stroke and death.

What medications are used in Dementia with Lewy Body

Acetylcholinesterase Inhibitors such as Rivastigmine

What are some non-epileptic seizures related to?

1.)Organic (e.g. hypoglycaemia, fever)

2.) Psychogenic (mental/emotional processes).

What are some common drugs used to treat seizures?

1.) Barbiturates=phenoarbital,primidone

2.)Benzodiazepines

3.)Carbamazepine

4.) Gabapentin

5.) Lacosamide

6.) Lamotrigine (long half life=ON)

7.) Levetiracetam

8.) Phenytoin (long half life=ON)

9.) Sodium Valproate

10.) Topiramate

What Category 1 Antiepileptic drugs are advised for patients to maintain on the same product (brand/manufacturer)?

1.) Carbamazepine, Phenytoin, Phenobarbital, Primidone (CP3)

2.) RX should include brand name/generic name+manufacturer

What are category 2 anti-epileptic meds

1.) valproate, lamotrigine, topimarate and clonazepam

2.) based on clinical judgement and patient consultation to switch products

What are category 3 anti-epileptics meds

1.)levetiracetam,gabapentin, pregabalin or ethoxusamide

2.) don’t need to be on same product

Why should abrupt withdrawal of antiepileptic drugs be avoided?

1.) Can precipitate severe rebound seizures

2.) withdraw one at time if on duotherpay

What is the general driving requirements for established epilepsy patients?

1.) got to be 1 year seizure-free

2.) no history of unprovoked seizures

3.) established seizure pattern where no influence on consciousness

What causes a driving ban

1.) during med changes or withdrawal

2.) 6 months after last dose

3.) 6 months for 1st unprovoked epileptic seizure

4.) 5 year ban for large goods

If the patient has seizures whilst asleep when can they drive

1.) history of no awake seizures for 1 year from 1st sleep seizure

2.) established pattern of sleep seizures for 3 years

What are the antiepileptic drugs with the highest risk of teratogenicity?

Valproate/Valproic Acid

What anti-epiletpic med can cause a cleft palate

topimarate in 1st trimester

What antiepileptic meds increase risk of a harmful pregnancy

carbamazepine, phenytoin,phenoarbital,primidone or lamotrgine

2.(CP3L)

What anti-epileptic med can affect oral contraceptives

carbamazepine

What vitamin is important during pregnancy in women taking anti-epileptic medication, and why?

1.) 5mg Folic acid OD to reduce the risk of neural tube defects

2.) take before conception and until week 12 of pregnancy

What are some key things regarding pregnancy and anti-epileptic meds

1.) plasma conc changes in pregnancy so may need to adjust dose

2.) monitor fetal growth for Topimarate/Levetiracetam

3.) giv Vit K injection in new borns

4.) notify UK epilepsy and preg-register

5.) withdrawal effects in newborns e.g. BZD+phenoarbital

What adverse effects should be monitored in newborns of mothers taking antiepileptic drugs?

Drowsiness, weight gain, feeding difficulty, adverse effects, developmental milestones

Which antiepileptic drugs are present in high amounts in breast milk?

Zonisamide, Ethosuximide, Lamotrigine, Primidone (ZELP)

What antiepileptic drug can inhibit sucking reflex

phenoarbital+primidone

What drugs during breastfeeding lead to drowsiness

1.) Bzds

2.) phenoarbital

3.) primidone

What are the symptoms of anti-epileptic hypersensitivity syndrome?

Rash, fever, lymphadenopathy and systemic involvement (occurs in first 1-8 weeks of starting medication)

drugs that cause this is CP3L (Carbamazepine, Phenytoin, Phenobarbital, Lamotrigine)

What is the patient counselling advice for all antiepileptic drugs related to suicidality?

Report any mood changes, distressing thoughts or feelings about suicide or self-harm.

What is the MHRA/CHM advice (October 2017) regarding Gabapentin?

increased risk of severe respiratory depression even without concomitant opoiid meds

What anti-epileptic meds causes blood dyscrasias

(CVETPLZ)

Carbamazepine

Valproate

Ethoxusimide

Topimarate

Phenytoin

Lamotrigine

Zonisamide

What anti-epileptic med causes visual field defects

Vigabatrin

What anti-epileptic meds cause skin rashes

Lamotrigine e.g. SJS

What anti-epileptic med can cause acute myopia with 2ndary angle closure glaucoma

topimarate

patient should be aware of raise intra-ocular pressure

What anti-epileptic med causes encepatholopic symptoms

vibagritin

What are some antiepileptic enzyme inhibitors?

Sodium Valproate leads to increase plasma conc

What are some antiepileptic enzyme inducers?

Carbamazepine, Phenytoin, Phenobarbital interacts with warfarin or oral contraceptives

What’s the mechanism of phenytoin

binds to neuronal sodium channels in their inactive states to prolong inactivity

What are the indications of phenytoin

1.) focal seizures

2.) generalised tonic-clonic seizures

When would you avoid phenytoin usage

exacerbates absence and myoclonic seizures

What’s the range of phenytoin

1.) 10-20mg/L or 40-80micromol/L

What are the signs of shymptoms of phenytoin toxicity

(SNACHD)

Slurred speech

Nystagmus

Ataxia

Confusion

Hyperglycaemia

Dipolpia

What plasma free-drug concentrations should be monitored when protein-binding is reduced?

pregnancy, children, elderly and liver failure.

What is important to note regarding switching between phenytoin products?

1.) Phenytoin formulations vary in bioavailability

2.) Phenytoin Sodium is NOT bioequivalent to Phenytoin Base.

3.) Dose conversion: 100mg Phenytoin sodium = 92mg Phenytoin base.

What are some signs of Phenytoin Hypersensitivity reaction?

Fever, rash, swollen lymph nodes

What are the side effects of phenytoin

1.) can cause rashes

2.) causes blood dyscrasias

3.) change in appearance: acne, hirsutism,gingvial hypertrophy

4.) low vit d=osteomalacia, rickets

5.) hepatotoxicity

6.) suicideal ideation

What should be monitored with intravenous phenytoin administration?

1.) ECG/BP due to bradycardia/hypotension

What is the prescription conversion for Fosphenytoin to Phenytoin?

Fosphenytoin 1.5mg = Phenytoin Sodium 1mg

What is the therapeutic range for Carbamazepine?

4-12mg/L or 20-50micromol/L

What adverse effect does the acronym i HANDBAG stand for related to carbamazepine toxicity?

Incoordination

Hyponatraemia

Ataxia

Nystagmus

Drowsiness

Blurred Vision

Arrhythmias

Gastro-Intestinal Disturbance

True or False: Han Chinese and Thai patients with HLAB*1502 allele are at risk of Steven-Johnson Syndrome with Carbamazepine.

True

What are the side effects of carbamazepine

1.) blood dsycrasia

2.) hepatotoxicity

3.) hypersensitivity reactions

4.) rashes

5.) hyponatraemia

What drugs decrease carbamazepine conc

1.) St john worts

2.) phenytoin

Which antiepileptic drug often requires a Pregnancy Prevention Programme?

Sodium Valproate

What actions should pharmacists take every time they dispense valproate for women

1.) Provide valproate PATIENT CARD

2.) Remind of risks in pregnancy/need for highly effective contraception,

3.) Remind of need for annual specialist review, dispense as whole pack

What are the side effects of sodium valproate

1.) hepatotoxicity

2.) blood dyscrasias

3.) pancreatitis

What are the drug interactions between sodium valproate that increase hepatotoxicity

1.) statins

2.) fluconazole

3.) Mtx

4.) carbamazepine

What drugs antagonise the anticonvusalant effect of sodium valproate

1.) quinolones

2.) mefloquine

3.) SSRIs

4.) Antipsychoitcs

5.) TCA

Is sodium valproate an enzyme inhibitor

Yes

What contraceptions are used for ppp for sodium valproate

1.) IUD,Pop implant, sterilisation

2.) COC+ condom and regular pregnancy test

What is first-line treatment for convulsive status epilepticus?

1.) Intravenous Lorazepam

2.) avoid IV diazepam as it causes thrombophlebtis

What’s the treatment for non convulsive status epilepticus

1.) if incomplete loss of awareness: give usual oral antiepileptic drug

2.) if complete loss of awareness or failure to oral antiepileptic drug: treat same as consulive status epilepectus

What is general treatment for febrile convulsions

Paracetamol (antipyretic), if >5 minutes treat the same as status epilepticus.

Which medications are given in the community for convulsive seizures or febrile seizures lasting >5 minutes?

1.) Diazepam Rectal Solution or Midazolam Oromucosal Solution

2.) repeated once after 10-15 minutes if necessary

What drugs increase carbamazepine conc

1.) cimetidine

2.) macrolides

3.) fluoxetine

4.) miconazole

What drugs can increase chance of hyponatraemia with carbamazepine

1.) SSRIs

2.) TCAs

3.) Diuretics

4.) NSAIDs

5.) aldosterone antagonists

What drugs can increase anticonvuslant effect

1.) Quinolones

2.) Mefloquine

3.) SSRIs

4.) Antipsychotics

5.) TCA

What drugs does carbamazepine affect

warfarin and oral contraceptives/HRT

it’s an enzyme inducer

What drugs interact with carbamazepine to increase hepatotoxicity

1.) tertracyclines

2.) MTX

3.)Alchohol

4.) statins

5.) fluconazole

What drugs reduce phenytoin conc

St John worts

Rifampicin

What drugs increase antifolate effect

1.) MTX

2.) trimethoprim

What drugs do phenytoin affect

warfarin

hormonal contraceptives/HRT

Corticosteroids

Levothyroxine/Liothryonine

What drugs increase phenytoin conc

Amiodarone

Macrolides

cimetidine

miconazole

flucanozole

What drugs antagonise anticonvuslant effect with phenytoin

1.) quinolones

2.) tramadol

3.) mefloquine

4.) SSRIs

5.) Antipsychotics

6.) TCA