1. Clinical Pharmacy 10 CNS

Outline the anatomy of the Brain.

What are the functions of the different parts of the brain?

Frontal lobe:

• Speech

• Problem solving

• Initiating movement

• Understanding emotions

• Influences character & personality

Parietal lobe:

• Recognition

• Touch, pressure & pain

Cerebellum:

• Balance & posture

• Timing & coordination of movement

Temporal lobe:

• Sound

• Memory storage

• Language processing

Occipital lobe:

• Vision

Brainstem:

• Breathing

• Sneezing & coughing

• Swallowing

• Heartbeat & blood pressure

What are the main principles for antiepileptic drug therapy?

• If monotherapy is ineffective or intolerable, try an alternative drug.

• Changing between drugs must be done carefully, only withdrawing the first drug once the new regimen is established.

• Combination therapy may be necessary but increases the risk of adverse effects and drug interactions.

• A single antiepileptic drug should be prescribed wherever possible.

Outline 1st & 2nd line treatment for focal, tonic-clonic & absence seizures.

Outline the emergency management for status epilepticus.

• Seizure lasting long or repeated seizures without regaining consciousness

• Medical emergency

• Position patient to avoid injury, support respiration, maintain blood pressure

• Follow emergency management plan (EMP) if available

• If no EMP, give buccal midazolam/rectal diazepam (community) or IV lorazepam (hospital)

• If no response, call emergency services or seek expert advice

• If seizure persists, give second dose of benzodiazepine

• Second-line treatment: levetiracetam, phenytoin, or sodium valproate

What is multiple sclerosis (MS) and its key features?

• Acquired immune-mediated inflammatory condition of the CNS

• Causes demyelination, gliosis, and secondary neuronal damage

• Common in young adults

• Most common non-traumatic cause of neurological disability in those under 40

• Cause unknown, but immune-mediated inflammation triggered by environmental factors

• Risk factors: genetic factors, vitamin D deficiency, infections, geographical location (higher prevalence farther from the equator), smoking, obesity during adolescence, and female gender (2-3x more common in females)

What are the most common symptoms of multiple sclerosis (MS)?

• Optic neuritis: Swelling of the optic nerve

• Transverse myelitis: Swelling of the spinal cord

• Cerebellar-related symptoms: Shakiness, coordination issues, slurred speech, trouble with higher-thinking skills

• Brainstem syndromes: Double vision, facial sensory issues, unstable gait, vertigo, facial weakness

What are the 3 main patterns of multiple sclerosis (MS)?

• Relapsing-remitting MS (RRMS): Most common – relapses with recovery & stability in between; damage builds up over time.

• Secondary progressive MS (SPMS): Gradual disability ↑ without relapses; affects 60–70% of RRMS patients.

• Primary progressive MS (PPMS): Continuous worsening from onset with no remissions; least common (10–15%).

How is multiple sclerosis (MS) diagnosed?

• Urgent referral to consultant neurologist (only they can diagnose MS)

• Blood tests to rule out other causes

• Diagnosis usually based on:

  • MRI scan → shows any damage to myelin sheath

  • Neurological assessment → assesses eye movements, limb strength, balance, coordination, speech & reflexes

  • Lumbar puncture → white cells in the CSF can indicate immune response to CNS damage

What are some disease modifying therapies (DMTs) for MS & their actions?

• Interferon β 1a/1b (SC injection) = balances pro- & anti-inflammatory agents in brain

• Glatiramer acetate (SC injection) = binds to MHC molecules & inhibits T cell response to myelin antigens

• Alemtuzumab (IV infusion) = depletes circulating T & B lymphocytes

• Common side effects = injection-site reactions, lipotrophy, chest tightness, headache, anxiety, nausea

How are specific MS symptoms treated?

• Baclofen = 1st line for chronic spasticity; start 5 mg TDS, ↑ gradually (usual 60 mg/day in 3 doses); max 100 mg/day; taper off slowly to avoid withdrawal (e.g. anxiety, seizures)

• Gabapentin = 2nd line for spasticity & oscillopsia (off-label); use neuropathic pain dosing

• Amitriptyline = for emotional lability (off-label); follow neuropathic pain dosing

How is an MS relapse managed?

• Rule out infection (esp. UTI or RTI)

• Consider disease fluctuation, progression, or other conditions

• Contact MS team promptly

• May give methylprednisolone 0.5 g/day PO for 5 days to ↓ relapse length & severity