Antipsychotic Drug Management Quiz
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Questions and Answers

What is the recommended duration for discontinuing antipsychotic drugs in cases of neuroleptic malignant syndrome?

  • At least 2 days
  • At least 5 days (correct)
  • At least 10 days
  • At least 7 days

    • Which of the following treatments have been used for neuroleptic malignant syndrome?

  • Carbamazepine and clozapine
  • Haloperidol and lorazepam
  • Bromocriptine and dantrolene (correct)
  • Lithium and valproate

    • Which monitoring parameter is NOT advised when starting therapy with antipsychotic drugs?

  • Cognitive functioning (correct)
  • Blood lipid concentrations
  • Weight
  • Liver function tests

    • What are the potential serious side effects mentioned regarding depot antipsychotics?

    <p>Hypotension and arrhythmias</p> Signup and view all the answers

    What should be monitored yearly during antipsychotic drug treatment?

    <p>Liver function tests, urea, and electrolytes</p> Signup and view all the answers

    Which condition may warrant the use of antipsychotic depot injections post-acute episode?

    <p>Psychosis or schizophrenia</p> Signup and view all the answers

    What is one potential consequence of chronic antipsychotic treatment while breastfeeding?

    <p>Potential adverse effects on the developing nervous system</p> Signup and view all the answers

    Which of the following is NOT listed as a very common adverse reaction to antipsychotic drugs?

    <p>Hair loss</p> Signup and view all the answers

    What is the recommended adjustment dosage for elderly patients taking haloperidol?

    <p>2-5 mg daily</p> Signup and view all the answers

    Which condition requires a dosage adjustment of 0.5-5 mg daily in haloperidol treatment?

    <p>Alzheimer's dementia</p> Signup and view all the answers

    What is a potential side effect common with haloperidol usage?

    <p>Weight decreased</p> Signup and view all the answers

    When should reassessment of haloperidol treatment occur?

    <p>Every 6-12 months</p> Signup and view all the answers

    What is a contraindication for the use of haloperidol?

    <p>Dehydration</p> Signup and view all the answers

    What is the recommended dosage adjustment range for acute psychomotor agitation associated with manic episodes of bipolar I disorder?

    <p>5-10 mg</p> Signup and view all the answers

    Which neurotransmitter receptors does haloperidol primarily antagonize?

    <p>Dopamine D2 and serotonin 5-HT2A</p> Signup and view all the answers

    What specific side effect is associated with parenteral use of haloperidol?

    <p>Hypertension</p> Signup and view all the answers

    What adjustment should be made for initial dosing of haloperidol in pregnant patients?

    <p>Halve the initial dose</p> Signup and view all the answers

    Which condition commonly associated with adverse reactions is contraindicated for haloperidol?

    <p>Congenital long QT syndrome</p> Signup and view all the answers

    How long should patients be observed after receiving each dose of loxapine?

    <p>1 hour</p> Signup and view all the answers

    For which condition is haloperidol recommended as a treatment option?

    <p>Acute psychosis</p> Signup and view all the answers

    What is the maximum initial dose for adults receiving haloperidol via injection for agitation?

    <p>9.1 mg</p> Signup and view all the answers

    Which medication form of haloperidol is available from special-order manufacturers?

    <p>Oral solution</p> Signup and view all the answers

    What should be monitored at the start of therapy for patients taking phenothiazine derivatives?

    <p>Prolactin concentration</p> Signup and view all the answers

    What is the typical initial dosage of Chlorpromazine hydrochloride for adults?

    <p>25 mg three times a day</p> Signup and view all the answers

    Which of the following is NOT a common side effect of Chlorpromazine hydrochloride?

    <p>Hearing loss</p> Signup and view all the answers

    How often should physical health monitoring be done for patients with schizophrenia?

    <p>Once a year</p> Signup and view all the answers

    What is the maximum dosage of flupentixol for adults in treating schizophrenia?

    <p>18 mg daily</p> Signup and view all the answers

    Which condition is a contra-indication for the use of flupentixol?

    <p>Excitable patients</p> Signup and view all the answers

    Children aged 1-5 years should receive which maximum dose of Chlorpromazine hydrochloride daily?

    <p>40 mg per day</p> Signup and view all the answers

    What is a recognized side effect related specifically to intramuscular use of Chlorpromazine?

    <p>Nasal congestion</p> Signup and view all the answers

    For patients on antipsychotic drugs not usually associated with hyperprolactinaemia, when should prolactin levels be monitored?

    <p>In symptomatic patients</p> Signup and view all the answers

    What is one of the side effects associated with the use of flupentixol?

    <p>Impaired glucose tolerance</p> Signup and view all the answers

    What dosage adjustment is suggested for elderly patients taking flupentixol?

    <p>Starting with the lowest adult dose</p> Signup and view all the answers

    What is emphasized regarding the use of antipsychotic medications in the management of agitation in dementia?

    <p>Careful prescribing and dispensing is crucial</p> Signup and view all the answers

    Which medication has specific contra-indications including CNS depression and comatose states?

    <p>Both medications</p> Signup and view all the answers

    What is one recommended action for patients taking antipsychotic drugs regarding their lifestyle?

    <p>Avoiding alcohol-induced drowsiness</p> Signup and view all the answers

    What is the recommended starting dosage for adults taking pericyazine for anxiety management?

    <p>15-30 mg daily in two divided doses</p> Signup and view all the answers

    Which medication is prescribed for monosymptomatic hypochondriacal psychosis?

    <p>Pimozide</p> Signup and view all the answers

    Which side effect is NOT commonly associated with phenothiazines?

    <p>Visual disturbances</p> Signup and view all the answers

    What is the maximum daily dose of pimozide for adults when treating schizophrenia?

    <p>40 mg per day</p> Signup and view all the answers

    In elderly patients, what is the recommended starting dose for prochlorperazine while managing schizophrenia?

    <p>Lower initial dose than younger adults</p> Signup and view all the answers

    Which of the following cautions is general when prescribing sulpiride?

    <p>Use with caution in aggressive or excited patients</p> Signup and view all the answers

    What form of prochlorperazine is specifically recommended for administration by placing it high between the upper lip and gum?

    <p>Buccastem M tablets</p> Signup and view all the answers

    For anxiety management in adults, what is the initial dosing range of prochlorperazine?

    <p>15-20 mg daily in divided doses</p> Signup and view all the answers

    Which of the following statements regarding the side effects of pimozide is correct?

    <p>It may result in skin reactions or face oedema</p> Signup and view all the answers

    What is the reason for monitoring blood concentrations of sulpiride in patients?

    <p>Following reports of sudden unexplained death</p> Signup and view all the answers

    Which condition is not a contraindication for using pimozide?

    <p>Urinary disorders</p> Signup and view all the answers

    When managing severe anxiety, what is the maximum recommended dose of pericyazine for adults?

    <p>60 mg daily</p> Signup and view all the answers

    What dosage adjustment method is recommended for pimozide?

    <p>Adjust at intervals of 4-7 days based on response</p> Signup and view all the answers

    What is the recommended maximum daily dosage for elderly patients using trifluoperazine?

    <p>150 mg</p> Signup and view all the answers

    Which condition is a contraindication for the use of Zuclopenthixol acetate?

    <p>Phaeochromocytoma</p> Signup and view all the answers

    What dosage adjustment is recommended for Trifluoperazine in elderly patients initially?

    <p>5-15 mg daily in divided doses</p> Signup and view all the answers

    What is the advised cumulative dose limit for Zuclopenthixol in a two-week period?

    <p>400 mg</p> Signup and view all the answers

    Which of the following is a potential side effect of Zuclopenthixol acetate?

    <p>Gait abnormality</p> Signup and view all the answers

    What is the maximum duration of treatment recommended for short-term use of Zuclopenthixol?

    <p>2 weeks</p> Signup and view all the answers

    What should be monitored regularly when administering potent first-generation antipsychotics?

    <p>Blood pressure</p> Signup and view all the answers

    What is the first-line treatment recommendation for adults requiring Zuclopenthixol?

    <p>50-150 mg as an initial dose</p> Signup and view all the answers

    Which of the following groups of patients should NOT use prochlorperazine buccal tablets?

    <p>Patients with severe hepatic impairment</p> Signup and view all the answers

    What safety information is critical when prescribing Zuclopenthixol?

    <p>It can worsen mania</p> Signup and view all the answers

    Which formulation of Trifluoperazine is NOT mentioned as available?

    <p>Inhalation aerosol</p> Signup and view all the answers

    For severe anxiety, what is the typical dosage recommendation?

    <p>2-4 mg daily in divided doses</p> Signup and view all the answers

    What is a common adverse reaction to medications used to treat schizophrenia?

    <p>Asthenia</p> Signup and view all the answers

    What injection site technique is recommended for administering oily injections?

    <p>Z-track technique</p> Signup and view all the answers

    What is the usual maintenance dose of haloperidol for adults?

    <p>50-200 mg every 4 weeks</p> Signup and view all the answers

    What is the maximum oral haloperidol dose allowed for elderly patients?

    <p>5 mg per day</p> Signup and view all the answers

    Which of the following conditions is a contraindication for using haloperidol?

    <p>Congenital long QT syndrome</p> Signup and view all the answers

    What is the recommended starting dose for elderly patients taking haloperidol?

    <p>12.5-25 mg every 4 weeks</p> Signup and view all the answers

    What are the potential side effects of haloperidol?

    <p>Gait abnormality, cardiac arrest, and dysphonia</p> Signup and view all the answers

    What special consideration must be taken when switching patients from oral to depot therapy of haloperidol?

    <p>Gradually reduce the oral dose</p> Signup and view all the answers

    Which monitoring procedure is necessary before initiating treatment with haloperidol?

    <p>ECG</p> Signup and view all the answers

    What is the advised volume limit for administering haloperidol injections at one site?

    <p>2-3 mL</p> Signup and view all the answers

    What is a key factor to consider when prescribing haloperidol for patients with renal impairment?

    <p>Half the normal dose for clearance less than 30 mL/min</p> Signup and view all the answers

    What is the maximum recommended dose of amisulpride for acute psychotic episodes?

    <p>1.2 g per day</p> Signup and view all the answers

    What should be done if creatinine clearance is between 10-30 mL/min for amisulpride?

    <p>Use one-third of the normal dose</p> Signup and view all the answers

    What should be done if haloperidol supplementation with oral haloperidol is required?

    <p>Total must not exceed the corresponding maximum oral dose</p> Signup and view all the answers

    What is the indication for monitoring serum drug concentration for amisulpride?

    <p>Patients presenting symptoms suggestive of toxicity</p> Signup and view all the answers

    What is a major contraindication for the use of clozapine?

    <p>Severe cardiac disorders</p> Signup and view all the answers

    Which of the following is a potential side effect of lurasidone hydrochloride?

    <p>QT interval prolongation</p> Signup and view all the answers

    Which medication is specifically recommended for adults aged 18-59 years to treat schizophrenia?

    <p>Clozapine</p> Signup and view all the answers

    What dosage is recommended for clozapine in adults aged 60 years and over when starting treatment?

    <p>25-37.5 mg daily</p> Signup and view all the answers

    Which monitoring parameter is not critical during the initial treatment with clozapine?

    <p>Chest X-ray</p> Signup and view all the answers

    What is a necessary action if symptoms of constipation develop in a patient taking clozapine?

    <p>Consult a doctor and possibly discontinue clozapine</p> Signup and view all the answers

    Which of the following is a side effect unique to clozapine compared to other antipsychotic medications?

    <p>Agranulocytosis</p> Signup and view all the answers

    What is the initial recommended dosage of quetiapine for elderly patients?

    <p>50 mg once daily</p> Signup and view all the answers

    What dosage adjustment is recommended for lurasidone when prescribed with moderate CYP3A4 inhibitors?

    <p>Decrease to 18.5 mg daily</p> Signup and view all the answers

    What condition is a caution when prescribing clozapine?

    <p>Age over 60 years</p> Signup and view all the answers

    Which of the following side effects is NOT commonly associated with quetiapine?

    <p>Hypoglycemia</p> Signup and view all the answers

    What is the function of administering clozapine with a gradual dosage increase?

    <p>To reduce the risk of side effects</p> Signup and view all the answers

    What dosage increase step is recommended for immediate-release quetiapine tablets?

    <p>25 mg daily</p> Signup and view all the answers

    Which potential side effect of clozapine poses an immediate risk requiring medical attention?

    <p>Fever with unknown origin</p> Signup and view all the answers

    What condition should be monitored in patients taking risperidone?

    <p>Blood concentrations for toxicity</p> Signup and view all the answers

    What is the primary reason for regular blood monitoring in patients taking clozapine?

    <p>To check for signs of agranulocytosis</p> Signup and view all the answers

    Which of the following is a common adverse effect of Lurasidone?

    <p>Hypersensitivity</p> Signup and view all the answers

    What is the lowest dosage available for Mintreleq XL?

    <p>150 mg</p> Signup and view all the answers

    Which of the following symptoms is a common side effect of quetiapine?

    <p>Fever</p> Signup and view all the answers

    Which condition is specifically contraindicated for the use of Lurasidone?

    <p>Severe renal impairment</p> Signup and view all the answers

    What should be done if a patient needs to discontinue clozapine abruptly?

    <p>Monitor closely for rebound psychosis</p> Signup and view all the answers

    What is the initial recommended daily dose of Olanzapine for adults when used as monotherapy?

    <p>15 mg</p> Signup and view all the answers

    What is a caution for prescribing quetiapine to patients?

    <p>Cerebrovascular disease</p> Signup and view all the answers

    Which medication is noted for having various formulations like orodispersible tablets for administering in patients?

    <p>Clozapine</p> Signup and view all the answers

    Which of the following side effects is specific to the use of Olanzapine?

    <p>Withdrawal syndrome</p> Signup and view all the answers

    For which demographic is risperidone recommended for treating aggressive behavior when nonpharmacological interventions fail?

    <p>Moderate to severe Alzheimer's dementia patients</p> Signup and view all the answers

    What precaution should be taken regarding Olanzapine when breastfeeding?

    <p>Breastfeeding should be avoided.</p> Signup and view all the answers

    What is a side effect associated with concomitant use of risperidone?

    <p>Withdrawal syndrome</p> Signup and view all the answers

    Which laboratory monitoring parameter should be conducted after initiating treatment with Olanzapine?

    <p>Fasting blood glucose</p> Signup and view all the answers

    Which of the following medications contains quetiapine?

    <p>Zaluron XL</p> Signup and view all the answers

    In the case of moderate to severe impairment, what is the dosage adjustment recommendation for Lurasidone?

    <p>Increase to 74 mg daily if necessary</p> Signup and view all the answers

    What is one of the most serious adverse effects associated with Olanzapine when used intramuscularly?

    <p>CNS and respiratory depression</p> Signup and view all the answers

    Which of these medications has a caution in usage during pregnancy with the condition that benefit must outweigh risk?

    <p>Olanzapine</p> Signup and view all the answers

    What form of Olanzapine is particularly noted to have dosage variability in patients?

    <p>Orodispersible tablets</p> Signup and view all the answers

    Which of the following should be monitored for patients taking Olanzapine?

    <p>Blood lipid levels</p> Signup and view all the answers

    What mental health condition is Lurasidone specifically used to treat?

    <p>Schizophrenia</p> Signup and view all the answers

    What is the effect of Lurasidone on appetite as a side effect?

    <p>Decreased appetite</p> Signup and view all the answers

    Which of the following conditions is NOT a side effect of Lurasidone?

    <p>Myeloproliferative disease</p> Signup and view all the answers

    What is the usual daily dosage range for aripiprazole in adults with schizophrenia?

    <p>10-15 mg</p> Signup and view all the answers

    Which side effect is not commonly associated with aripiprazole?

    <p>Alopecia</p> Signup and view all the answers

    When administering aripiprazole via intramuscular injection for maintenance, how often should it be given?

    <p>Every month</p> Signup and view all the answers

    What should be done for 14 consecutive days after the first injection of aripiprazole?

    <p>Continue the prescribed daily dose of oral aripiprazole</p> Signup and view all the answers

    In what population should aripiprazole use be approached with caution?

    <p>Elderly individuals</p> Signup and view all the answers

    Which information is relevant regarding the prescribing of aripiprazole to pregnant women?

    <p>Benefits must outweigh the risks before prescribing</p> Signup and view all the answers

    What is the primary receptor activity of aripiprazole?

    <p>Dopamine D2 partial agonism</p> Signup and view all the answers

    Which medication interaction requires careful monitoring of blood concentrations for aripiprazole?

    <p>CYP3A4 inducers</p> Signup and view all the answers

    What form of aripiprazole allows for dissolution on the tongue?

    <p>Orodispersible tablets</p> Signup and view all the answers

    Which condition is not listed as a caution when prescribing aripiprazole?

    <p>Hypertension</p> Signup and view all the answers

    What is a notable rare side effect of aripiprazole?

    <p>Cataracts</p> Signup and view all the answers

    Which of the following is true regarding breastfeeding while taking aripiprazole?

    <p>It is advised to avoid breastfeeding</p> Signup and view all the answers

    What is the appropriate response if a patient presents symptoms suggestive of toxicity from aripiprazole?

    <p>Monitor blood concentrations for toxicity</p> Signup and view all the answers

    What should patients be advised regarding the dosage adjustment of aripiprazole due to drug interactions?

    <p>Consult product literature for appropriate adjustments</p> Signup and view all the answers

    What is the usual daily dosage range for adults prescribed paliperidone?

    <p>3-12 mg</p> Signup and view all the answers

    Which of the following conditions is NOT a caution for the use of paliperidone?

    <p>Healthy metabolism</p> Signup and view all the answers

    When transitioning from oral to depot therapy with paliperidone, how should the oral dosage be adjusted?

    <p>Reduced gradually</p> Signup and view all the answers

    What is the primary reason for adjusting the maintenance dose of Xeplion® pre-filled syringes?

    <p>To match the patient's creatinine clearance</p> Signup and view all the answers

    What is a recommended administration guideline for administering intramuscular paliperidone?

    <p>Rotate injection sites</p> Signup and view all the answers

    What dosage of paliperidone is recommended for maintenance after stabilization on once-monthly intramuscular treatment?

    <p>50 mg</p> Signup and view all the answers

    Which potential effect is NOT associated with paliperidone?

    <p>Weight loss</p> Signup and view all the answers

    Which of the following forms of quetiapine dosing is recommended for elderly patients?

    <p>50 mg once daily</p> Signup and view all the answers

    What should a patient be advised regarding the long-acting nature of paliperidone?

    <p>It can be detected in plasma for up to 18 months</p> Signup and view all the answers

    In cases requiring dosage adjustment for quetiapine, what is the usual titration speed for elderly patients?

    <p>Titration should be slower</p> Signup and view all the answers

    What is a significant side effect of paliperidone that may affect patient compliance?

    <p>Skin reactions</p> Signup and view all the answers

    What is the dosing strategy for managing acute mania in bipolar disorder using quetiapine?

    <p>50 mg and increase to 200 mg</p> Signup and view all the answers

    What product is indicated for maintaining treatment in adults who are clinically stable on one-monthly paliperidone palmitate?

    <p>Trevicta</p> Signup and view all the answers

    What is the correct method for administering orodispersible tablets of risperidone?

    <p>Place the tablets on the tongue and allow them to dissolve.</p> Signup and view all the answers

    Which of the following is a side effect commonly associated with the use of olanzapine?

    <p>Eosinophilia</p> Signup and view all the answers

    Which adverse reaction is noted as rare or very rare when using risperidone?

    <p>Angioedema</p> Signup and view all the answers

    How should risperidone be stored when not refrigerated?

    <p>At room temperature below 25°C for up to 7 days</p> Signup and view all the answers

    What monitoring is recommended after administering olanzapine injections?

    <p>Observing the patient for at least 3 hours post-injection</p> Signup and view all the answers

    When using risperidone in cases of hepatic impairment, what is the recommended dose adjustment?

    <p>Reduce to half the usual dose</p> Signup and view all the answers

    Which injection technique is advised for the administration of risperidone?

    <p>Z-track technique for intramuscular use</p> Signup and view all the answers

    What is the initial recommended dose of olanzapine for patients transferring from oral therapy to depot therapy?

    <p>210mg every 2 weeks</p> Signup and view all the answers

    Which of the following is NOT a form available for risperidone?

    <p>Capsule</p> Signup and view all the answers

    In the event of an overdose of olanzapine, which of the following is a possible side effect?

    <p>Visual hallucinations</p> Signup and view all the answers

    What should be considered when administering olanzapine to pregnant patients?

    <p>Potential benefits must outweigh risks</p> Signup and view all the answers

    Which of the following is a common very adverse effect of risperidone?

    <p>Chest discomfort</p> Signup and view all the answers

    What condition requires additional caution when using olanzapine?

    <p>Cardiac conduction disorders</p> Signup and view all the answers

    Which dietary consideration should be made when administering oral liquid risperidone?

    <p>May be diluted with any non-alcoholic drink, except tea</p> Signup and view all the answers

    What is a critical contraindication for the use of botulinum toxin type A?

    <p>Acute urinary retention</p> Signup and view all the answers

    In patients with mild to moderate impairment, what is the recommended initial dosage adjustment for a drug contraindicated for them?

    <p>50% dose reduction</p> Signup and view all the answers

    Which specific caution should be considered when administering botulinum toxin type A for blepharospasm?

    <p>Risk of angle-closure glaucoma</p> Signup and view all the answers

    Which condition is commonly associated with the use of botulinum toxin type A that may require immediate medical attention?

    <p>Dysphagia</p> Signup and view all the answers

    What type of preparations for botulinum toxin are explicitly indicated to not be interchangeable?

    <p>Injection powders</p> Signup and view all the answers

    Which side effect is very common with botulinum toxin type B?

    <p>Muscle weakness</p> Signup and view all the answers

    What is the purpose of using botulinum toxin type A in patients with chronic migraine?

    <p>To prevent headaches</p> Signup and view all the answers

    Which medication form is available from special-order manufacturers for botulinum toxin?

    <p>Oral suspension</p> Signup and view all the answers

    What is a symptom of Parkinson's disease that affects non-motor functions?

    <p>Depression</p> Signup and view all the answers

    What is the recommended frequency for reviewing patients suspected of Parkinson's disease?

    <p>Every 6 to 12 months</p> Signup and view all the answers

    What should a patient with a confirmed diagnosis of Parkinson's disease inform once diagnosed?

    <p>DVLA and car insurer</p> Signup and view all the answers

    Which side effect is commonly associated with botulinum toxin preparations?

    <p>Facial paralysis</p> Signup and view all the answers

    What is the primary aim of treatment in patients diagnosed with Parkinson's disease?

    <p>To manage symptoms and improve quality of life</p> Signup and view all the answers

    What should patients and caregivers be made aware of concerning botulinum toxin injections?

    <p>Signs of toxin spread include muscle weakness</p> Signup and view all the answers

    Which of the following statements about cerebral palsy is accurate?

    <p>Cerebral palsy results from permanent brain abnormalities during development.</p> Signup and view all the answers

    What is a common treatment focus for motor neurone disease?

    <p>Maintaining functional ability and managing symptoms.</p> Signup and view all the answers

    Which drug is used specifically for treating muscle cramps in patients with motor neurone disease?

    <p>Quinine</p> Signup and view all the answers

    Which condition may require the use of botulinum toxin type A for treatment?

    <p>Severe spasticity after a non-progressive brain injury.</p> Signup and view all the answers

    Which medication is primarily used to manage essential tremor?

    <p>Propranolol hydrochloride</p> Signup and view all the answers

    Which of the following medications should be prescribed carefully due to its potential side effects?

    <p>Promazine hydrochloride</p> Signup and view all the answers

    Which medication is used to extend life in amyotrophic lateral sclerosis patients?

    <p>Riluzole</p> Signup and view all the answers

    What is the recommended initial dosing strategy for Tetrabenazine in elderly patients?

    <p>Lower initial dose due to increased sensitivity</p> Signup and view all the answers

    Which of the following side effects is associated with Chlorpromazine hydrochloride?

    <p>Increased risk of cardiac arrest</p> Signup and view all the answers

    Which non-drug treatment is appropriate for managing symptoms of motor neurone disease?

    <p>Psychosocial support and exercise programs</p> Signup and view all the answers

    Which medication is used for treating tardive dyskinesia when withdrawal of the antipsychotic is not effective?

    <p>Tetrabenazine</p> Signup and view all the answers

    Which of the following treatments is NOT used for respiratory symptoms in motor neurone disease?

    <p>Riluzole</p> Signup and view all the answers

    Which is true regarding the pharmacological treatment of dystonias?

    <p>Requires careful dose increases over time for some medications</p> Signup and view all the answers

    How can essential tremor associated with anxiety be managed?

    <p>Propranolol hydrochloride or other beta blockers</p> Signup and view all the answers

    Which condition should NOT be treated with antidepressants unless well tolerated in Parkinson's disease patients?

    <p>Depression</p> Signup and view all the answers

    What is the maximum daily dosage of procyclidine prescribed for adults in treating Parkinson's disease?

    <p>15-30 mg</p> Signup and view all the answers

    In managing nocturnal akinesia, which of the following is considered a second-line option if initial treatments fail?

    <p>Midodrine hydrochloride</p> Signup and view all the answers

    Which of the following drugs should be administered two days prior to starting apomorphine therapy to prevent nausea?

    <p>Domperidone</p> Signup and view all the answers

    What type of therapy is advised as adjuvant treatment for patients with motor fluctuations despite optimal levodopa therapy?

    <p>Deep brain stimulation</p> Signup and view all the answers

    What is the initial recommended dose of procyclidine for Parkinson's disease in adults?

    <p>2.5 mg three times a day</p> Signup and view all the answers

    Which of the following treatments is appropriate for managing rapid eye movement sleep behavior disorder in Parkinson's disease patients?

    <p>Melatonin</p> Signup and view all the answers

    Which medication is considered for managing impulse control disorders in Parkinson's disease patients?

    <p>Quetiapine</p> Signup and view all the answers

    In advanced Parkinson's disease, which treatment options are available for patients whose symptoms are not managed with drug therapy?

    <p>Continuous subcutaneous infusions</p> Signup and view all the answers

    What is a key consideration for patients taking long-term treatment with procyclidine?

    <p>Avoid abrupt withdrawal</p> Signup and view all the answers

    Which of the following conditions should be treated with lower dose ranges of procyclidine?

    <p>Acute dystonia</p> Signup and view all the answers

    What common side effect is associated with procyclidine treatment in Parkinson's disease patients?

    <p>Urinary retention</p> Signup and view all the answers

    Which of the following should be taken into account before prescribing dopamine receptor agonists?

    <p>Patient's age and comorbidities</p> Signup and view all the answers

    Which of the following is NOT a commonly recognized treatment for drooling of saliva in Parkinson's disease patients?

    <p>Antipsychotic medication</p> Signup and view all the answers

    Which of the following side effects is NOT associated with levodopa?

    <p>Peptic ulcer</p> Signup and view all the answers

    What is the advised action if a patient is transferring from immediate-release levodopa preparations to Caramet CR?

    <p>Discontinue the previous preparation 12 hours before the first dose</p> Signup and view all the answers

    Which side effect requires specific caution due to its impact on activities such as driving or operating machinery?

    <p>Excessive daytime sleepiness</p> Signup and view all the answers

    What is the primary recommendation for managing excessive daytime sleepiness in patients taking co-beneldopa?

    <p>Identify underlying cause</p> Signup and view all the answers

    Which of the following is a potential side effect of levodopa usage during pregnancy?

    <p>Urinary impairment</p> Signup and view all the answers

    Which disorder should patients and their carers be informed about as a risk of long-term levodopa treatment?

    <p>Pathological gambling</p> Signup and view all the answers

    What adjustment is recommended when switching from modified-release levodopa to dispersible co-beneldopa?

    <p>Reduce dose by approximately 30%</p> Signup and view all the answers

    Which of the following is a common misconception regarding levodopa side effects?

    <p>It has no impact on sexual function</p> Signup and view all the answers

    Which of the following conditions would NOT typically be considered a contraindication for levodopa treatment?

    <p>Mild allergic reaction</p> Signup and view all the answers

    What potential effect does levodopa have on lactation during breastfeeding?

    <p>Suppresses lactation</p> Signup and view all the answers

    What is the recommended daily dosage of trihexyphenidyl for adults in managing Parkinson's disease?

    <p>2-6 mg</p> Signup and view all the answers

    Which of the following conditions is NOT a contraindication for using trihexyphenidyl?

    <p>Diabetes mellitus</p> Signup and view all the answers

    What is a recommended precaution for patients taking tolcapone for Parkinson's disease?

    <p>Monitor liver function regularly</p> Signup and view all the answers

    Which side effect is common with medications used to treat Parkinson's disease?

    <p>Dry mouth</p> Signup and view all the answers

    Entacapone primarily functions by inhibiting which enzyme?

    <p>Catechol-O-methyltransferase</p> Signup and view all the answers

    Which of the following side effects could indicate serious complications when using tolcapone?

    <p>Neuroleptic malignant syndrome</p> Signup and view all the answers

    What is a contraindication for the use of opicapone?

    <p>Phaeochromocytoma</p> Signup and view all the answers

    Which of the following side effects is associated with the use of co-careldopa?

    <p>Malignant melanoma</p> Signup and view all the answers

    What should patients be counseled about when starting treatment with co-careldopa?

    <p>Risk of sudden sleep onset</p> Signup and view all the answers

    What is the maximum daily dosage of entacapone when used in conjunction with levodopa?

    <p>2 g</p> Signup and view all the answers

    In which situation should the dosage of levodopa be reduced when using tolcapone?

    <p>More than 500 mg of levodopa per day</p> Signup and view all the answers

    Which condition requires discontinuation of the previous levodopa preparation at least 12 hours before starting co-careldopa?

    <p>Switching from another levodopa preparation</p> Signup and view all the answers

    What is the advised timing for taking opicapone in relation to levodopa?

    <p>At least one hour before or after levodopa</p> Signup and view all the answers

    What is a potential risk associated with the abrupt cessation of co-careldopa treatment?

    <p>Neuroleptic malignant syndrome</p> Signup and view all the answers

    Which of the following conditions is NOT specifically mentioned as a side effect of entacapone?

    <p>Weight gain</p> Signup and view all the answers

    Which of the following is NOT a recommended caution when using co-careldopa in pregnant or breastfeeding patients?

    <p>Worsening anxiety symptoms</p> Signup and view all the answers

    What should be the focus in managing excessive daytime sleepiness in patients taking co-careldopa?

    <p>Identifying an underlying cause</p> Signup and view all the answers

    What general precaution is advised for patients with hepatic impairment when using opicapone?

    <p>Use with caution in moderate impairment</p> Signup and view all the answers

    What should be avoided in patients who are on long-term treatment with these medications?

    <p>Abrupt discontinuation</p> Signup and view all the answers

    In cases of agranulocytosis, what warning should patients and their carers be informed about?

    <p>Risk of developing dopamine dysregulation syndrome</p> Signup and view all the answers

    Which patient population is specifically cautioned due to the risk of toxicity when using trihexyphenidyl?

    <p>Elderly individuals</p> Signup and view all the answers

    Which side effect indicates the need for caution when prescribing co-careldopa to patients?

    <p>Gastrointestinal haemorrhage</p> Signup and view all the answers

    What is a defining characteristic of dopamine dysregulation syndrome for patients on co-careldopa?

    <p>Addiction-like symptoms</p> Signup and view all the answers

    What neurological condition is specifically mentioned for treatment with Co-careldopa (Duodopa®)?

    <p>Advanced levodopa-responsive Parkinson's disease</p> Signup and view all the answers

    Which of the following medicinal forms is NOT associated with special-order manufacturers?

    <p>Dextrose solution</p> Signup and view all the answers

    What is the maximum dosage for adults taking modified-release tablets?

    <p>10 tablets per day</p> Signup and view all the answers

    In the context of transferring to Stalevo®, what adjustment is recommended for patients receiving more than 800mg of levodopa daily?

    <p>Introduce entacapone before transferring to Stalevo</p> Signup and view all the answers

    Which combination is specifically shown to control end-of-dose motor fluctuations in Parkinson's disease?

    <p>Levodopa with carbidopa and a dopadecarboxylase inhibitor</p> Signup and view all the answers

    For what condition has the Scottish Medicines Consortium recommended Co-careldopa (Duodopa®)?

    <p>Advanced levodopa-responsive Parkinson's disease</p> Signup and view all the answers

    What precaution should patients be advised of when starting treatment with dopaminergic medications?

    <p>Risk of excessive sedation</p> Signup and view all the answers

    What adjustment is suggested for patients receiving standard-release co-careldopa before beginning Stalevo®?

    <p>Similar (or slightly lower) amount of levodopa</p> Signup and view all the answers

    Which statement accurately describes the intention behind the use of Stalevo® in patients already on dopaminergic therapy?

    <p>To achieve better control of Parkinson's symptoms</p> Signup and view all the answers

    What condition is contraindicated for the use of bromocriptine?

    <p>Pregnancy complications</p> Signup and view all the answers

    What monitoring is required for patients starting treatment with cabergoline?

    <p>Echocardiography for cardiac fibrosis</p> Signup and view all the answers

    What is the maximum daily dose for cabergoline when treating Parkinson's disease?

    <p>3.3 mg</p> Signup and view all the answers

    What should be the first action if a patient on bromocriptine develops hypertension?

    <p>Discontinue immediately</p> Signup and view all the answers

    What common adverse effect is associated with dopamine-receptor agonists like cabergoline?

    <p>Decreased blood pressure</p> Signup and view all the answers

    Which of the following is NOT advised as a warning for patients starting dopamine-receptor agonists?

    <p>Immediate cessation of medication if headaches occur</p> Signup and view all the answers

    Which patient population should be established for hyperprolactinaemia prior to undergoing treatment?

    <p>Patients with fertility issues</p> Signup and view all the answers

    Which condition requires caution when prescribing dopamine-receptor agonists due to potential adverse effects?

    <p>History of peptic ulcer</p> Signup and view all the answers

    What is an important step before initiating treatment with ergot-derived dopamine receptor agonists?

    <p>Assess for cardiac valvulopathy</p> Signup and view all the answers

    Which of the following side effects is associated with prolonged use of dopamine-receptor agonists?

    <p>Impulse control disorders</p> Signup and view all the answers

    What is the recommended initial dosing guideline for patients starting cabergoline for Parkinson's disease?

    <p>88 micrograms three times a day</p> Signup and view all the answers

    What management approach should be taken for excessive daytime sleepiness in patients on dopamine-receptor agonists?

    <p>Identify the underlying cause</p> Signup and view all the answers

    Which strategy is vital for mitigating the risk of neuroleptic malignant syndrome in patients on dopaminergic treatment?

    <p>Gradual tapering of medication</p> Signup and view all the answers

    What should be monitored when discontinuing antiparkinsonian drug therapy to avoid potential risks?

    <p>Risk of neuroleptic malignant syndrome</p> Signup and view all the answers

    What should a patient be educated about concerning the side effects of cabergoline?

    <p>Possible gastrointestinal distress</p> Signup and view all the answers

    Which of the following medications is specifically included as a dopamine-receptor agonist?

    <p>Pramipexole</p> Signup and view all the answers

    Which dosage of modified-release medications for Parkinson's disease represents the initial starting point?

    <p>2 mg once daily</p> Signup and view all the answers

    What is a common side effect associated with the use of dopamine-receptor agonists?

    <p>Anxiety</p> Signup and view all the answers

    What should patients and their carers be informed about when starting treatment with dopamine-receptor agonists?

    <p>The risk of impulse control disorders</p> Signup and view all the answers

    In what manner are immediate-release medications for restless legs syndrome typically dosed?

    <p>Doubled every 4-7 days</p> Signup and view all the answers

    How should the adjustment of levodopa dosing be approached based on patient response?

    <p>Reduced or maintained based on tolerance</p> Signup and view all the answers

    Which condition is NOT supported by dopamine-receptor agonists for treatment?

    <p>Excessive daytime sleepiness</p> Signup and view all the answers

    When initiating therapy with dopamine-receptor agonists, what behavior modification is recommended?

    <p>Counsel on improving sleep behavior</p> Signup and view all the answers

    What should be done if a patient experiences excessive daytime sleepiness while on dopamine-receptor agonists?

    <p>Refrain from driving or operating machinery</p> Signup and view all the answers

    What is one possible side effect of switching between dopamine-receptor agonists?

    <p>Worsening of impulse control disorders</p> Signup and view all the answers

    Which medication is suggested to not be used alongside dopaminergic therapy due to potential increased side effects?

    <p>Antipsychotics</p> Signup and view all the answers

    What is a characteristic of the titration schedule for the initial dose of modified-release medication for Parkinson's disease?

    <p>Weekly adjustments with potential doubling</p> Signup and view all the answers

    Which of the following is a key concern for patients using dopamine-receptor agonists?

    <p>Impulse control disorders</p> Signup and view all the answers

    What is a potential serious reaction patients should be cautious of when using dopamine-receptor agonists?

    <p>Hypotensive reactions</p> Signup and view all the answers

    Which of the following medications is administered through a transdermal patch?

    <p>Rotigotine</p> Signup and view all the answers

    What is the recommended initial dose of Rotigotine for patients?

    <p>2 mg/24 hours</p> Signup and view all the answers

    Patients taking dopamine-receptor agonists need to be especially careful when engaging in which activities?

    <p>Driving or operating machinery</p> Signup and view all the answers

    Which of the following side effects is NOT associated with Rotigotine treatment?

    <p>Increased appetite</p> Signup and view all the answers

    Which of these versions of Ropinirole is used specifically for idiopathic Parkinson's Disease?

    <p>ReQuip XL®</p> Signup and view all the answers

    What caution must patients and carers take into account regarding impulse control when using dopamine-receptor agonists?

    <p>Risk of impulse control disorders</p> Signup and view all the answers

    Which medication can be prescribed as adjunctive therapy for Parkinson's disease?

    <p>Co-beneldopa</p> Signup and view all the answers

    What should patients starting treatment with dopamine-receptor agonists be counseled on?

    <p>Improving sleep behavior</p> Signup and view all the answers

    How is Ropinirole primarily made available in medicinal forms?

    <p>Oral tablets and suspensions</p> Signup and view all the answers

    Regarding therapy initiation with dopamine-receptor agonists, what aspect should be closely monitored?

    <p>Potential for loss of consciousness</p> Signup and view all the answers

    Which of the following is an official recommendation from the Scottish Medicines Consortium regarding Ropinirole?

    <p>Recommended with restrictions</p> Signup and view all the answers

    What is a shared common side effect between both Ropinirole and Rotigotine treatments?

    <p>Skin reactions</p> Signup and view all the answers

    What is the maximum dose patients can increase to with Rotigotine patches over time?

    <p>8 mg/24 hours</p> Signup and view all the answers

    Which of the following side effects is specifically associated with Safinamide?

    <p>Cataract</p> Signup and view all the answers

    What condition is considered a contraindication for the use of Rasagiline?

    <p>Retinal degeneration</p> Signup and view all the answers

    What common psychiatric side effect can be caused by medications mentioned in the document?

    <p>Cognitive disorder</p> Signup and view all the answers

    Which medication among those discussed is a monoamine-oxidase B inhibitor used for Parkinson's disease treatment?

    <p>Selegiline</p> Signup and view all the answers

    Which of the following medications is advised to be avoided during pregnancy due to toxicity concerns?

    <p>Safinamide</p> Signup and view all the answers

    Which side effect is NOT associated with Selegiline according to the details provided?

    <p>Increased risk of infection</p> Signup and view all the answers

    What specific side effect is highlighted in relation to dopamine dysregulation syndrome?

    <p>Pathological gambling</p> Signup and view all the answers

    What is a common side effect of Levodopa when adjusted for elderly patients?

    <p>Nausea</p> Signup and view all the answers

    What is one of the advised precautions when taking antipsychotic drugs according to the document?

    <p>Caution with skilled tasks</p> Signup and view all the answers

    What is a side effect related to the use of Safinamide that may trigger concern?

    <p>Peripheral oedema</p> Signup and view all the answers

    How is Selegiline typically dosed for immediate-release medications?

    <p>5 mg once daily, increasing to 10 mg</p> Signup and view all the answers

    Which medication is particularly noted for having hypersensitivity reactions like rash or pruritus?

    <p>Safinamide</p> Signup and view all the answers

    What side effect may indicate the need to reevaluate treatment with antipsychotic medications?

    <p>Psychotic episodes</p> Signup and view all the answers

    What is a common recommendation for healthcare professionals regarding the dosing of Selegiline?

    <p>Titrate based on patient response</p> Signup and view all the answers

    What are the potential adverse effects of domperidone that patients and caregivers should be aware of?

    <p>Increased risk of ventricular arrhythmia</p> Signup and view all the answers

    Which of the following conditions is a contraindication for the use of metoclopramide?

    <p>Gastro-intestinal obstruction</p> Signup and view all the answers

    What is the maximum recommended daily dose of metoclopramide in adults?

    <p>500 micrograms/kg</p> Signup and view all the answers

    What specific side effects are associated with metoclopramide that worsen with age?

    <p>Acute dystonic reactions</p> Signup and view all the answers

    What common side effect may occur with high doses or long-term use of metoclopramide?

    <p>Hyperprolactinemia</p> Signup and view all the answers

    Which method is recommended for administering intravenous doses of metoclopramide?

    <p>As a slow bolus over at least 3 minutes</p> Signup and view all the answers

    What drug is administered before chemotherapy to prevent nausea and vomiting?

    <p>Fosaprepitant</p> Signup and view all the answers

    For which of the following reasons should caution be exercised in prescribing metoclopramide?

    <p>Liver impairment</p> Signup and view all the answers

    What is a noted side effect of fosaprepitant?

    <p>Gastrointestinal discomfort</p> Signup and view all the answers

    What is the maximum recommended daily dosage of Amantadine hydrochloride?

    <p>100 mg</p> Signup and view all the answers

    What specific dosing adjustment is required for patients with end-stage renal disease taking metoclopramide?

    <p>Reduce daily dose by 75%</p> Signup and view all the answers

    Which of the following conditions should be avoided when prescribing dopamine-receptor agonists?

    <p>Cardiovascular disease</p> Signup and view all the answers

    What form does metoclopramide NOT come in for administration?

    <p>Topical patch</p> Signup and view all the answers

    Which of the following behaviors is contraindicated for patients on metoclopramide?

    <p>Use while pregnant unless absolutely necessary</p> Signup and view all the answers

    Which medication has been linked to impulse control disorders such as pathological gambling?

    <p>All of the above</p> Signup and view all the answers

    What is a potential risk of abruptly discontinuing antiparkinsonian drug therapy?

    <p>Neuroleptic malignant syndrome</p> Signup and view all the answers

    One of the side effects of neurokinin receptor antagonists includes which of the following?

    <p>Severe cutaneous adverse reactions</p> Signup and view all the answers

    Which of the following symptoms should be monitored in patients taking dopamine-receptor agonists?

    <p>Postural hypotension</p> Signup and view all the answers

    Which form of Amantadine hydrochloride is NOT mentioned as available?

    <p>Injectable</p> Signup and view all the answers

    Which of the following is a contraindication for the use of Amantadine hydrochloride?

    <p>Respiratory depression</p> Signup and view all the answers

    What is an important counseling point for patients starting treatment with apomorphine?

    <p>It may cause excessive daytime sleepiness.</p> Signup and view all the answers

    Which substance should NOT be used with caution in patients taking dopamine-receptor agonists?

    <p>Nicotine</p> Signup and view all the answers

    Which of the following is a common side effect when using dopamine-receptor agonists?

    <p>Nausea</p> Signup and view all the answers

    What is the recommended approach for managing excessive daytime sleepiness in patients?

    <p>Identify and treat underlying cause.</p> Signup and view all the answers

    Which dosage form of apomorphine is advisable for administration?

    <p>Intravenous injection</p> Signup and view all the answers

    In patients taking Amantadine, what is crucial to monitor for long-term use?

    <p>Liver function</p> Signup and view all the answers

    What mechanism does apomorphine primarily affect in the brain?

    <p>Dopamine receptors</p> Signup and view all the answers

    What is the correct duration for using effective nonhormonal contraception during and after fosaprepitant treatment?

    <p>2 months after stopping treatment</p> Signup and view all the answers

    Which of the following statements is true regarding the administration of the Granisetron patch?

    <p>It must be removed at least 24 hours post-chemotherapy</p> Signup and view all the answers

    What is the recommended dosage for preventing postoperative nausea and vomiting with Granisetron?

    <p>1 mg before induction of anesthesia</p> Signup and view all the answers

    What precaution should be taken regarding Ondansetron use in pregnant patients?

    <p>It is advised against during the first 12 weeks of pregnancy</p> Signup and view all the answers

    What is the maximum dose of Ondansetron that can be given in a 24-hour period?

    <p>16 mg</p> Signup and view all the answers

    Which of the following side effects is specifically associated with Granisetron?

    <p>Flushing</p> Signup and view all the answers

    Which administration method for Palonosetron is utilized in severely emetogenic chemotherapy?

    <p>Intravenous injection</p> Signup and view all the answers

    What is the key caution regarding the Granisetron patch regarding sun exposure?

    <p>Avoid exposing the site to sunlight during use and for 10 days after removal</p> Signup and view all the answers

    How should fosaprepitant be reconstituted for intravenous infusion?

    <p>Reconstitute with 5 mL sodium chloride 0.9% gently</p> Signup and view all the answers

    What is a contraindication for Ondansetron use?

    <p>Congenital long QT syndrome</p> Signup and view all the answers

    What is the initial dose of Palonosetron for moderately emetogenic chemotherapy?

    <p>500 micrograms orally 1 hour before treatment</p> Signup and view all the answers

    In what form is Ondansetron available for administration?

    <p>In oral, intravenous, and transdermal forms</p> Signup and view all the answers

    What is a suggested maximum daily dosage of Ondansetron for elderly patients?

    <p>8 mg</p> Signup and view all the answers

    Which antiemetic is preferred for treating nausea and vomiting associated with gastro-intestinal and biliary disease?

    <p>Metoclopramide hydrochloride</p> Signup and view all the answers

    What is a characteristic of domperidone in relation to the blood-brain barrier?

    <p>It does not cross the blood-brain barrier easily.</p> Signup and view all the answers

    Which type of medications are indicated for managing nausea and vomiting in patients receiving cytotoxics?

    <p>5HT3-receptor antagonists</p> Signup and view all the answers

    Which medication is considered for use in palliative care for relief of nausea and vomiting?

    <p>Haloperidol</p> Signup and view all the answers

    What potential benefit does prochlorperazine offer to patients with severe nausea and vomiting?

    <p>Available as a buccal tablet</p> Signup and view all the answers

    Which type of antiemetic is reported to be ineffective for motion sickness?

    <p>Phenothiazines</p> Signup and view all the answers

    Which medication is a synthetic cannabinoid used for chemotherapy-induced nausea and vomiting?

    <p>Nabilone</p> Signup and view all the answers

    What caution should be observed when prescribing antihistamines for nausea?

    <p>They may cause sedation and dizziness.</p> Signup and view all the answers

    In managing motion sickness, what is the maximum adult dosage for cyclizine?

    <p>50 mg up to three times daily</p> Signup and view all the answers

    What is an appropriate non-pharmacological option for mild to moderate nausea?

    <p>Ginger</p> Signup and view all the answers

    Which antiemetic is indicated for both postoperative nausea and vomiting as well as chemotherapy-induced nausea?

    <p>Dexamethasone</p> Signup and view all the answers

    For women in pregnancy experiencing nausea, which antiemetic is often recommended?

    <p>Doxylamine with pyridoxine</p> Signup and view all the answers

    What is the primary action of phenothiazines in managing nausea and vomiting?

    <p>Dopamine antagonism at the central level</p> Signup and view all the answers

    What is one condition that often increases the incidence of postoperative nausea and vomiting?

    <p>Prolonged surgery</p> Signup and view all the answers

    Which side effect is considered a rare or very rare occurrence with palonosetron?

    <p>Shock</p> Signup and view all the answers

    What forms of palonosetron are available from special-order manufacturers?

    <p>Oral suspension and orodispersible film</p> Signup and view all the answers

    What potential side effect of antihistamines is particularly concerning in elderly patients?

    <p>Anticholinergic syndrome</p> Signup and view all the answers

    What is advised regarding the use of antihistamines in pregnancy?

    <p>Use should be avoided due to potential risks</p> Signup and view all the answers

    Which condition is mentioned as a caution when using antihistamines?

    <p>Severe renal impairment</p> Signup and view all the answers

    What adverse effect is associated with the use of sedating antihistamines in neonates?

    <p>Tremor</p> Signup and view all the answers

    What general side effect of palonosetron is common among patients?

    <p>Drowsiness</p> Signup and view all the answers

    What recommendation is given for women of childbearing age before treatment with palonosetron?

    <p>Ensure effective contraception</p> Signup and view all the answers

    Which of the following medications is used for preventing motion sickness in children aged 5-9 years?

    <p>Promethazine teoclate</p> Signup and view all the answers

    What is highlighted about the effects of alcohol on patients taking sedating antihistamines?

    <p>It enhances sedating effects</p> Signup and view all the answers

    What specific side effect is associated with the use of palonosetron during chemotherapy?

    <p>QT interval prolongation</p> Signup and view all the answers

    What adverse effects may antihistamines cause in neonates during the third trimester?

    <p>Paradoxical excitability</p> Signup and view all the answers

    What action should be taken for administering orodispersible films of palonosetron?

    <p>Place on the tongue and allow to dissolve</p> Signup and view all the answers

    In which of the following scenarios should antihistamines be avoided?

    <p>Renal impairment</p> Signup and view all the answers

    What impact do antihistamines have on skilled tasks like cycling or driving?

    <p>They may impair performance due to drowsiness</p> Signup and view all the answers

    What is the advised action regarding prochlorperazine for children under 6 years?

    <p>Over-the-counter formulations are not recommended</p> Signup and view all the answers

    What is the purpose of administering hyoscine hydrobromide before anesthesia?

    <p>To prevent nausea and vomiting</p> Signup and view all the answers

    What is a significant contraindication for using droperidol?

    <p>Hypokalemia</p> Signup and view all the answers

    What must be monitored when patients with renal impairment are treated with droperidol?

    <p>Continuous pulse oximetry</p> Signup and view all the answers

    What should be considered before administering levomepromazine to elderly patients?

    <p>Postural hypotension risk</p> Signup and view all the answers

    What side effect is associated with hyoscine hydrobromide?

    <p>Eyelid irritation</p> Signup and view all the answers

    Which medication is not licensed for treating hypersalivation associated with clozapine therapy?

    <p>Hyoscine hydrobromide</p> Signup and view all the answers

    What characterizes the proper administration of antimuscarinic drugs during general anesthesia?

    <p>Direct supervision by experienced personnel</p> Signup and view all the answers

    For palliative care, what method is recommended for children's use of hyoscine patches?

    <p>Placement behind the ear</p> Signup and view all the answers

    What is the recommended dosage range for levomepromazine in children aged 1-11 years?

    <p>100-400 micrograms/kg over 24 hours</p> Signup and view all the answers

    What is a key warning regarding the use of levomepromazine?

    <p>Can result in asthmatic reactions</p> Signup and view all the answers

    Which medication's maximum daily dosage is advised to be limited to 5 mg per day?

    <p>Droperidol</p> Signup and view all the answers

    Which of the following conditions is cyclizine NOT indicated for treatment?

    <p>Hypotension</p> Signup and view all the answers

    What is the primary risk associated with cyclizine use during the third trimester of pregnancy?

    <p>Potential adverse effects in neonates</p> Signup and view all the answers

    Which of the following is a specific side effect associated with parenteral administration of cyclizine?

    <p>Decreased level of consciousness</p> Signup and view all the answers

    Which vitamin is mentioned as being commonly confused with cyclizine due to its therapeutic applications?

    <p>Vitamin B6</p> Signup and view all the answers

    What is advised regarding the administration of mixtures containing cyclizine and diamorphine?

    <p>They should not be mixed at concentrations above 10 mg/mL.</p> Signup and view all the answers

    Why is Xonvea not recommended for women who do not respond to conservative management?

    <p>Health authorities have not endorsed its usage.</p> Signup and view all the answers

    Which side effect is commonly associated with nabilone?

    <p>Hallucinations</p> Signup and view all the answers

    How should domperidone administration be approached in patients with renal impairment?

    <p>Consider dose reduction and reduce frequency.</p> Signup and view all the answers

    What is a unique characteristic of drug formulations containing cyclizine?

    <p>Different formulations can be licensed differently.</p> Signup and view all the answers

    Which of the following adverse effects is most commonly associated with domperidone?

    <p>QT interval prolongation</p> Signup and view all the answers

    What specific advice should be given to patients taking cyclizine regarding performance of skilled tasks?

    <p>Drowsiness may impair performance and should be avoided.</p> Signup and view all the answers

    In children aged 12-17, what has been concluded about domperidone's effectiveness?

    <p>Alternative treatments are more effective.</p> Signup and view all the answers

    What potential consequence may occur after stopping nabilone treatment?

    <p>Adverse effects on the mental state may persist.</p> Signup and view all the answers

    Which analgesic is generally preferred over aspirin in elderly patients due to its lower stomach irritant properties?

    <p>Paracetamol</p> Signup and view all the answers

    What is a common side effect associated with morphine when used as an opioid analgesic?

    <p>Nausea and vomiting</p> Signup and view all the answers

    Which drug may precipitate withdrawal symptoms in patients who are dependent on other opioids?

    <p>Buprenorphine</p> Signup and view all the answers

    Which combinations of analgesics can provide greater pain relief when used in adequate doses?

    <p>Ibuprofen and paracetamol</p> Signup and view all the answers

    Which condition could be effectively treated with a muscle relaxant like diazepam during the acute phase?

    <p>Temporomandibular dysfunction</p> Signup and view all the answers

    What potential side effects are linked with nefopam hydrochloride?

    <p>Synapthomimetic and antimuscarinic</p> Signup and view all the answers

    For which type of pain are opioid analgesics particularly indicated?

    <p>Moderate to severe pain, especially visceral</p> Signup and view all the answers

    What duration of postoperative analgesia is typical for patients using NSAIDs?

    <p>24 to 72 hours</p> Signup and view all the answers

    Which opioid is known for having a longer duration of action than morphine and is effective sublingually?

    <p>Buprenorphine</p> Signup and view all the answers

    Which pain management approach involves using multiple classes of analgesics?

    <p>Multimodal analgesia</p> Signup and view all the answers

    What type of medications are selective inhibitors of cyclo-oxygenase-2 preferred over?

    <p>Non-selective NSAIDs</p> Signup and view all the answers

    What is a significant concern when giving a postoperative opioid analgesic?

    <p>Potential for respiratory depression</p> Signup and view all the answers

    Which drug acts for longer periods than morphine and should not be administered more than twice daily due to the risk of overdose?

    <p>Methadone hydrochloride</p> Signup and view all the answers

    Which pain condition is correctly matched with a suitable treatment?

    <p>Dysmenorrhea - Non-steroidal anti-inflammatory drugs</p> Signup and view all the answers

    Which dosage range is recommended for adults taking Levomepromazine hydrochloride?

    <p>16 mg to 48 mg daily</p> Signup and view all the answers

    What type of pain is chronic pain defined as?

    <p>Pain present for more than 12 weeks</p> Signup and view all the answers

    Which type of analgesics should be considered for managing moderate-to-severe pain?

    <p>Opioid analgesics like morphine</p> Signup and view all the answers

    Which of the following is a potential risk of opioid use?

    <p>Addiction and overdose</p> Signup and view all the answers

    What are the categories of secondary pain caused by underlying conditions?

    <p>Post-surgical and cancer-related</p> Signup and view all the answers

    How frequently should opioids be reviewed in a treatment plan?

    <p>Annually</p> Signup and view all the answers

    Which medication is NOT recommended for managing pain in sickle-cell disease?

    <p>Pethidine hydrochloride</p> Signup and view all the answers

    What is a notable reason why Pethidine hydrochloride is generally not recommended for postoperative pain?

    <p>It metabolizes to norpethidine, which can accumulate in renal impairment.</p> Signup and view all the answers

    What role does depression have in individuals with chronic pain?

    <p>It is a common comorbidity and should be monitored</p> Signup and view all the answers

    Which non-drug treatment can be beneficial for managing chronic pain?

    <p>Transcutaneous electrical nerve stimulation (TENS)</p> Signup and view all the answers

    Which of the following best describes the use of Patient-controlled analgesia (PCA)?

    <p>It allows patients to self-administer pain relief.</p> Signup and view all the answers

    Which statement is true regarding the administration of Penthrox®?

    <p>It requires experienced personnel for self-administration.</p> Signup and view all the answers

    What is an important consideration when prescribing opioids long-term?

    <p>Engage the patient in understanding potential harms</p> Signup and view all the answers

    What is a characteristic of chronic primary pain?

    <p>Has no clear underlying condition</p> Signup and view all the answers

    What adverse effect is NOT commonly associated with the use of methoxyflurane?

    <p>Severe respiratory depression</p> Signup and view all the answers

    Which condition is a contraindication for the use of methoxyflurane?

    <p>Cardiovascular disease</p> Signup and view all the answers

    How is Betahistine dihydrochloride primarily used?

    <p>For managing labyrinth disorders and nausea</p> Signup and view all the answers

    What is the purpose of the WHO analgesic ladder?

    <p>To guide the treatment of chronic and acute pain</p> Signup and view all the answers

    What is one of the interactions associated with paracetamol use?

    <p>Interactions leading to severe neutropenia</p> Signup and view all the answers

    What specific dose adjustments should be made for intravenous paracetamol in patients with compromised renal function?

    <p>Adjust the infusion interval to every 6 hours if creatinine clearance is 30 mL/min or less.</p> Signup and view all the answers

    What additional caution should be taken into account when administering medications like paracetamol to children under 16 years?

    <p>It's not licensed for their use in certain conditions.</p> Signup and view all the answers

    Which side effect is considered very rare with paracetamol use?

    <p>Severe cutaneous adverse reactions (SCARs)</p> Signup and view all the answers

    Why should the administration of Penthrox® be minimized in handling and storage?

    <p>There is a risk of serious side effects.</p> Signup and view all the answers

    What condition may imply the need for caution when using methoxyflurane in patients?

    <p>Pregnancy and breastfeeding</p> Signup and view all the answers

    What is a major limitation of transdermal buprenorphine patches?

    <p>They do not provide steady-state analgesia quickly.</p> Signup and view all the answers

    Which factor could increase the risk of paracetamol toxicity in treated patients?

    <p>Body weight under 50 kg</p> Signup and view all the answers

    What must patients be on before switching to the Sixmo® subcutaneous implant?

    <p>A stable daily buprenorphine dose of 2 to 8 mg for at least 30 days.</p> Signup and view all the answers

    Why is it recommended to prescribe buprenorphine by brand name?

    <p>To minimize risks of confusion and prescribing errors.</p> Signup and view all the answers

    What is one of the side effects of using opioids administered epidurally?

    <p>Urinary retention</p> Signup and view all the answers

    What dosing recommendation is typically advised for adults using methoxyflurane?

    <p>3-6 mL as required, avoiding consecutive days.</p> Signup and view all the answers

    Driving and skilled tasks should be advised against due to which side effect of buprenorphine?

    <p>Risk of somnolence lasting up to one week.</p> Signup and view all the answers

    Which statement about Espranor oral lyophilisate is accurate?

    <p>It has different bioavailability and is not interchangeable.</p> Signup and view all the answers

    Which buprenorphine product is recommended specifically for chronic non-malignant pain?

    <p>Butec® transdermal patches.</p> Signup and view all the answers

    What should patients or carers do if spontaneous expulsion occurs for subcutaneous buprenorphine implants?

    <p>Seek immediate medical attention.</p> Signup and view all the answers

    Which of the following statements regarding buprenorphine forms is NOT accurate?

    <p>All forms of buprenorphine are interchangeable without restriction.</p> Signup and view all the answers

    Which of the following medications is primarily indicated for moderate pain in adults and the elderly?

    <p>Nefopam hydrochloride</p> Signup and view all the answers

    What is a significant risk associated with co-prescribing opioids and benzodiazepines?

    <p>Additive CNS depressant effects</p> Signup and view all the answers

    What is the recommended maximum daily dose of aspirin with codeine for adults?

    <p>8 tablets</p> Signup and view all the answers

    Which side effect is NOT commonly associated with Nefopam hydrochloride?

    <p>Hypertension</p> Signup and view all the answers

    What precaution should be taken when prescribing opioids to elderly patients?

    <p>Avoid strong opioids as first-line therapy</p> Signup and view all the answers

    In the context of opioid use, which condition warrants close monitoring post-prescription adjustments?

    <p>Respiratory depression</p> Signup and view all the answers

    What should be considered when tapering opioid dosage at the end of treatment?

    <p>Reduce dosage slowly to avoid withdrawal symptoms</p> Signup and view all the answers

    Which side effect is a common consequence of opioid overdose?

    <p>Respiratory depression</p> Signup and view all the answers

    Which medication form of paracetamol is available in powder form?

    <p>650 mg oral powder sachets</p> Signup and view all the answers

    What condition may arise from prolonged use of opioids even at therapeutic doses?

    <p>Opioid dependence and addiction</p> Signup and view all the answers

    What type of drug is buprenorphine classified as?

    <p>Opioid-receptor partial agonist</p> Signup and view all the answers

    Which of the following conditions serves as a contraindication for opioid use?

    <p>Acute respiratory depression</p> Signup and view all the answers

    Which statement is true regarding the potential adverse effects of longer-term opioid therapy?

    <p>Withdrawal symptoms may occur with abrupt cessation</p> Signup and view all the answers

    What is the recommended initial dose of sublingual buprenorphine for adults on their first day of treatment?

    <p>0.8-4 mg</p> Signup and view all the answers

    Which of the following is a contraindication for using SIXMO® implants?

    <p>Magnetic resonance imaging (MRI)</p> Signup and view all the answers

    What is the maximum daily dosage for intranasal analgesia in adults receiving buprenorphine?

    <p>18 mg</p> Signup and view all the answers

    How long should transdermal patches be evaluated for their analgesic effect?

    <p>At least 24 hours</p> Signup and view all the answers

    Which of these side effects is associated specifically with the sublingual use of buprenorphine?

    <p>Angioedema</p> Signup and view all the answers

    What adjustment should be made before inserting subcutaneous buprenorphine implants?

    <p>Discontinue all opioids 24 hours prior</p> Signup and view all the answers

    For which condition is premedication specifically recommended?

    <p>Simultaneous analgesia during a procedure</p> Signup and view all the answers

    What should be evaluated after a transdermal buprenorphine system has been worn for at least 3 days?

    <p>Pharmacokinetics</p> Signup and view all the answers

    What is the advised frequency for dose adjustment of transdermal buprenorphine patches?

    <p>At least every 3 days</p> Signup and view all the answers

    Which medication should be avoided due to the risk of very rare side effects and inflexible dosing during pregnancy?

    <p>Buprenorphine</p> Signup and view all the answers

    Which side effect is commonly associated with buprenorphine transdermal patches?

    <p>Increased risk of infection</p> Signup and view all the answers

    What is the terminal half-life for the monthly injections of Buvidal®?

    <p>19-25 days</p> Signup and view all the answers

    Which condition is not recommended for using unlicensed buprenorphine transdermal patches?

    <p>Children under 6 years</p> Signup and view all the answers

    For adults aged 18-65 years, how much subcutaneous buprenorphine is typically administered via implants?

    <p>296.8 mg</p> Signup and view all the answers

    What is the microgram dosage per hour of buprenorphine contained in Bunov?

    <p>20 micrograms</p> Signup and view all the answers

    Which of the following medications is recommended for opioid dependence management?

    <p>Methadone</p> Signup and view all the answers

    Which dosage of buprenorphine is contained in Butec?

    <p>20 micrograms per hour</p> Signup and view all the answers

    What is the recommended method of using buprenorphine medications?

    <p>In conjunction with other medications</p> Signup and view all the answers

    Which buprenorphine product is NOT cited as having a microgram dosage of 35?

    <p>Butec</p> Signup and view all the answers

    Which of the following medications is priced at £7.92 DT?

    <p>Butec</p> Signup and view all the answers

    Which combination of drugs is involved in the formulation of buprenorphine for pain management?

    <p>Buprenorphine and paracetamol</p> Signup and view all the answers

    Which organization recommended buprenorphine implants and injections?

    <p>Scottish Medicines Consortium (SMC)</p> Signup and view all the answers

    What is the maximum dose per episode of breakthrough pain for adults receiving fentanyl therapy?

    <p>1.2 mg</p> Signup and view all the answers

    What form of administration is recommended for breakthrough pain in patients receiving opioid therapy for chronic cancer pain?

    <p>Buccal administration using lozenges</p> Signup and view all the answers

    What should healthcare professionals remember regarding the use of fentanyl patches in opioid-naive patients?

    <p>Use can lead to serious side effects.</p> Signup and view all the answers

    What effect should be monitored when using transdermal fentanyl patches in patients with fever?

    <p>Increased side effects</p> Signup and view all the answers

    What is a common side effect associated with the intravenous administration of fentanyl?

    <p>Muscle rigidity</p> Signup and view all the answers

    Which of the following should NOT be done when applying a fentanyl patch?

    <p>Apply to hairy skin</p> Signup and view all the answers

    What adjustment is advised for weight-based dosing in obese patients using fentanyl?

    <p>Calculate based on ideal body weight</p> Signup and view all the answers

    What is the correct initial dose for children aged 16-17 receiving fentanyl for breakthrough pain?

    <p>200 micrograms</p> Signup and view all the answers

    What advice should be given regarding lozenges for patients with diabetes?

    <p>Each lozenge includes approximately 2 g glucose.</p> Signup and view all the answers

    Which of the following statements about fentanyl films is correct?

    <p>They are not bioequivalent to other fentanyl preparations.</p> Signup and view all the answers

    In managing breakthrough pain with buccal films for adults, what should be done after placing the film?

    <p>Hold it in place for at least 5 seconds.</p> Signup and view all the answers

    What is a recognized uncommon side effect of fentanyl use?

    <p>Joint disorders</p> Signup and view all the answers

    What is the advised dose adjustment for patients with hepatic conditions using fentanyl?

    <p>Cautious dose adjustments are necessary.</p> Signup and view all the answers

    What should be done for patients with renal impairment when prescribing co-codamol?

    <p>Consider adjusting the dose</p> Signup and view all the answers

    What is the maximum daily dose of codeine for adolescents aged 12-18 years?

    <p>240 mg</p> Signup and view all the answers

    In which scenario should co-codamol not be used for children under 18 years old?

    <p>After tonsillectomy for obstructive sleep apnoea</p> Signup and view all the answers

    Which condition is a contraindication for the use of co-codamol?

    <p>Chronic dehydration</p> Signup and view all the answers

    What side effect is associated with the use of codeine?

    <p>Agranulocytosis</p> Signup and view all the answers

    What is a caution that should be taken into account when prescribing codeine phosphate?

    <p>Active ulcerative colitis</p> Signup and view all the answers

    Which patient group is advised against using co-codamol due to potential adverse reactions?

    <p>Children with severely compromised breathing</p> Signup and view all the answers

    Which of the following is true regarding metabolism variations in codeine?

    <p>Ultra-rapid metabolizers can experience increased morphine toxicity</p> Signup and view all the answers

    What is the recommended dosage for codeine phosphate in treating acute moderate pain in children aged 12 years and older?

    <p>30-60 mg every four hours if required</p> Signup and view all the answers

    What should manufacturers advise regarding breastfeeding and co-codamol?

    <p>Breastfeeding should be avoided due to codeine content</p> Signup and view all the answers

    What legal category restrictions apply to the prescribing of co-codamol?

    <p>It is classified as a controlled substance with exceptions</p> Signup and view all the answers

    What warning is given regarding the use of co-codamol in cases of hepatic impairment?

    <p>Monitor closely in mild to moderate impairment</p> Signup and view all the answers

    Which of the following is correct about the dispensing of co-codamol labeled as 'dispersible'?

    <p>It can be dispensed against an order for 'effervescent'</p> Signup and view all the answers

    What should be noted about the dosage of codeine for acute diarrhea?

    <p>30 mg three to four times a day</p> Signup and view all the answers

    What is the maximum daily dosage for adults taking Dihydrocodeine tartrate combined with paracetamol for severe pain?

    <p>240 mg of Dihydrocodeine and 4000 mg of paracetamol</p> Signup and view all the answers

    Which of the following is a potential side effect of Dihydrocodeine tartrate?

    <p>Phaeochromocytoma</p> Signup and view all the answers

    For children aged 12-17 years experiencing chronic severe pain, what is the recommended dosage range for modified-release Dihydrocodeine?

    <p>60-120 mg every 12 hours</p> Signup and view all the answers

    In adults requiring opioid analgesia via intramuscular injection for acute pain, what is the significant dosage consideration mentioned?

    <p>Dosing is adjusted according to patient response.</p> Signup and view all the answers

    What combination of side effects is associated with Dihydrocodeine, emphasizing caution in specific scenarios?

    <p>Biliary spasm and increased intracranial pressure</p> Signup and view all the answers

    What is the advice given regarding prescribing dihydrocodeine with paracetamol to minimize risks to patients?

    <p>Prescribe by strength to minimize dosing errors.</p> Signup and view all the answers

    What is the advised initial dosing for children aged 16-17 years using transdermal application for chronic intractable pain?

    <p>12 micrograms/hour every 72 hours</p> Signup and view all the answers

    Which special caution is advised when prescribing fentanyl in pediatric patients?

    <p>Close monitoring for sedation and respiratory issues.</p> Signup and view all the answers

    For chronic pain not currently treated with a strong opioid, what method of administration is recommended?

    <p>Transdermal application</p> Signup and view all the answers

    Which of the following describes the advised approach when converting from long-term oral morphine to transdermal fentanyl?

    <p>Consider previous opioid requirements for dosage adjustment.</p> Signup and view all the answers

    What form of Dihydrocodeine is particularly mentioned for being available from special-order manufacturers?

    <p>Extended-release tablets</p> Signup and view all the answers

    What is indicated regarding the dosage adjustment for cases of renal impairment when using Dihydrocodeine?

    <p>Reduce the dosage or closely monitor effects.</p> Signup and view all the answers

    What is the maximum dosage of immediate-release Dihydrocodeine recommended for children aged 4-11 years resting on given guidelines?

    <p>20 mg every 4-6 hours</p> Signup and view all the answers

    What is a common misconception regarding withdrawal symptoms in infants of dependent mothers?

    <p>Using dihydrocodeine is the main treatment for dependency.</p> Signup and view all the answers

    What is a key instruction for patients using fentanyl patches?

    <p>Seek medical attention immediately if breathing difficulties occur.</p> Signup and view all the answers

    Which of the following medications is specifically recommended for managing breakthrough pain in adults already receiving opioid therapy?

    <p>Fentanyl pectin nasal spray (PecFent®)</p> Signup and view all the answers

    What is one potential side effect of hydromorphone hydrochloride?

    <p>Sleep disturbances</p> Signup and view all the answers

    What dosage adjustment is recommended for pediatric patients aged 12-17 years using hydromorphone hydrochloride?

    <p>1.3 mg every 4 hours for immediate-release and 4 mg every 12 hours for modified-release</p> Signup and view all the answers

    Which medication form is available from special-order manufacturers for fentanyl?

    <p>Infusion and solution for injection</p> Signup and view all the answers

    What should be done if fentanyl patches cause marked drowsiness?

    <p>Seek immediate medical attention and remove the patch.</p> Signup and view all the answers

    Which of the following dosing regimens is NOT appropriate for fentanyl buccal tablets Effentora?

    <p>500 micrograms</p> Signup and view all the answers

    Which risk is associated with hydromorphone hydrochloride that requires caution?

    <p>Hepatic impairment</p> Signup and view all the answers

    What is the main concern regarding the disposal of fentanyl patches?

    <p>They must be discarded properly to prevent accidental exposure.</p> Signup and view all the answers

    What is the correct action for patients about to administer hydromorphone hydrochloride capsules?

    <p>The capsules must be taken whole or sprinkled on soft food.</p> Signup and view all the answers

    Which medication is indicated for treating severe pain in cancer patients specifically?

    <p>Hydromorphone hydrochloride</p> Signup and view all the answers

    What dosage form of Fentanyl is NOT commercially available?

    <p>Extended release capsules</p> Signup and view all the answers

    Which side effect associated with hydromorphone hydrochloride should be monitored in patients?

    <p>Constipation</p> Signup and view all the answers

    What should be the priority during acute respiratory issues associated with fentanyl usage?

    <p>Remove the fentanyl patch and seek medical help.</p> Signup and view all the answers

    What is a common side effect of morphine that might lead to increased patient discomfort?

    <p>Erectile dysfunction</p> Signup and view all the answers

    Which dosage adjustment is recommended for elderly patients using Meptazinol?

    <p>5 mg every 4 hours</p> Signup and view all the answers

    Which condition is a contraindication for using morphine?

    <p>Myocardial infarction</p> Signup and view all the answers

    What is the recommended approach for patients with renal impairment when prescribing opioids?

    <p>Reduce dosage in moderate to severe impairment</p> Signup and view all the answers

    What dosage is advised for morphine in managing palliative care patients?

    <p>30 mg every 4 hours</p> Signup and view all the answers

    What is a potential effect of an overdose of morphine?

    <p>Profound sedation not reversible</p> Signup and view all the answers

    What dosage information is crucial when administering morphine modifications?

    <p>The correct preparation prescribed</p> Signup and view all the answers

    What is the route of administration for patient-controlled analgesia (PCA) using morphine?

    <p>Intravenous</p> Signup and view all the answers

    Which of the following is an uncommon side effect of morphine?

    <p>Hypotension</p> Signup and view all the answers

    What adjustment should be made for patients switching from a regular weak opioid to morphine?

    <p>Reduce daily dosage by 20-30%</p> Signup and view all the answers

    What is the correct dosage of morphine for obstetric analgesia?

    <p>2 mg/kg</p> Signup and view all the answers

    Which of these forms is NOT available for administering morphine?

    <p>Topical cream</p> Signup and view all the answers

    What is advised regarding breastfeeding while on morphine?

    <p>Use only if potential benefit outweighs the risk</p> Signup and view all the answers

    For which pediatric age group is Meptazinol dosed at 100-200 micrograms/kg every 4 hours?

    <p>Children 2-11 years</p> Signup and view all the answers

    What action should be taken if morphine hydrochloride exceeds 13 mg per 5mL?

    <p>It becomes a schedule 2 controlled drug.</p> Signup and view all the answers

    Which of the following is NOT a form of morphine available from special-order manufacturers?

    <p>Sublingual tablet</p> Signup and view all the answers

    What dosages is Oramorph available in for modified-release treatment?

    <p>10 mg every 12 hours maximum of 200 mg</p> Signup and view all the answers

    Which condition is considered when switching between oxycodone formulations?

    <p>2 mg oral oxycodone is equivalent to 1 mg parenteral oxycodone.</p> Signup and view all the answers

    In which situation can modified-release medications be recommended for adults?

    <p>With a maximum daily dose of 400 mg.</p> Signup and view all the answers

    What is a possible side effect associated with opioid medications?

    <p>Mood alterations</p> Signup and view all the answers

    Which of the following modified-release tablets is NOT mentioned as an available option for morphine?

    <p>Oramorph SR</p> Signup and view all the answers

    What is the advised maximum dosage of oxycodone for severe pain?

    <p>400 mg per day for immediate-release.</p> Signup and view all the answers

    Which statement regarding the side effects of morphine is accurate?

    <p>Cognitive impairment can occur.</p> Signup and view all the answers

    What represents a dosing equivalence between formulations of oxycodone?

    <p>5 mg oral is equal to 1 mg parenteral.</p> Signup and view all the answers

    What warning is pertinent when prescribing medications like morphine and oxycodone?

    <p>They can lead to dependence and withdrawal.</p> Signup and view all the answers

    How should prescriptions for morphine be specified?

    <p>The form must be clearly stated.</p> Signup and view all the answers

    What is the equivalent dosage when considering patient-controlled analgesia (PCA) with morphine?

    <p>5 mg per hour is typical.</p> Signup and view all the answers

    What is a potential side effect that may occur specifically with oral use of opioids?

    <p>Cognitive impairment.</p> Signup and view all the answers

    What is the maximum recommended dosage of Oxycodone hydrochloride for moderate to severe pain per day?

    <p>600 mg</p> Signup and view all the answers

    Which medication is suggested in combination with naloxone for treating severe idiopathic restless legs syndrome?

    <p>Oxycodone hydrochloride</p> Signup and view all the answers

    What is the common starting dosage of Tapentadol for managing acute pain?

    <p>50 mg every 4-6 hours</p> Signup and view all the answers

    What is one of the potential side effects associated with Pethidine hydrochloride?

    <p>Hypotension</p> Signup and view all the answers

    Which dosage form of Oxycodone hydrochloride allows for administration via injection?

    <p>Intravenous</p> Signup and view all the answers

    For patients with severe impairment, which medication requires dose adjustments and has a maximum dosage of 50-100 mg?

    <p>Pethidine hydrochloride</p> Signup and view all the answers

    What is the maximum initial dosage for adults receiving Oxycodone hydrochloride through injection for severe pain?

    <p>10 mg/mL</p> Signup and view all the answers

    What is the typical adjustment period for dosage of Oxycodone hydrochloride when used with naloxone?

    <p>Weekly</p> Signup and view all the answers

    What is the specified maximum daily dosage for Oxycodone hydrochloride when treating severe pain?

    <p>360 mg</p> Signup and view all the answers

    How is the dosage of Oxycodone combined with naloxone expressed?

    <p>x/y in mg</p> Signup and view all the answers

    What is one of the risks associated with using Pentazocine?

    <p>Limited prescribing availability</p> Signup and view all the answers

    What is the usual dosing interval recommended for Oxycodone hydrochloride taken for moderate pain?

    <p>Every 3-4 hours</p> Signup and view all the answers

    Which condition may lead to toxicity when combined with Pentazocine?

    <p>Severe continuing pain</p> Signup and view all the answers

    What should be avoided when prescribing tapentadol to a patient with a history of seizures?

    <p>Combining with medications that decrease seizure threshold</p> Signup and view all the answers

    Which condition requires special caution when using tramadol for postoperative pain relief in children?

    <p>Obstructive sleep apnea</p> Signup and view all the answers

    Which of the following side effects is rare and associated with tapentadol use?

    <p>Seizures</p> Signup and view all the answers

    What dosage adjustment is recommended for tramadol in patients with moderate hepatic impairment?

    <p>Reduce the initial daily dose</p> Signup and view all the answers

    What advice should patients receive regarding the administration of orodispersible tramadol tablets?

    <p>They can be dispersed in water before consumption</p> Signup and view all the answers

    Which medication should not be used for narcotic withdrawal treatment due to specific contraindications?

    <p>Tramadol hydrochloride</p> Signup and view all the answers

    What is one of the generic side effects of tramadol that users should be aware of?

    <p>Postural hypotension</p> Signup and view all the answers

    Which of the following is advisable regarding the administration of modified-release tramadol tablets?

    <p>They should be swallowed whole with water</p> Signup and view all the answers

    Which chemical substances are known to potentially interact with tapentadol, raising the risk of serotonin syndrome?

    <p>Serotonergic antidepressants</p> Signup and view all the answers

    What is the effect of withdrawing serotonergic medication in cases of serotonin syndrome?

    <p>It usually results in rapid improvement</p> Signup and view all the answers

    What is the maximum recommended dosage for adults using tramadol within a 24-hour period?

    <p>400 mg</p> Signup and view all the answers

    Which form of tramadol is not suitable for administration in acute intoxication scenarios?

    <p>Intravenous injection</p> Signup and view all the answers

    What should prescribers take into account when dispensing tramadol to ensure patient safety?

    <p>Potential medication interactions and formulation</p> Signup and view all the answers

    What is the recommended dosage of tramadol hydrochloride for elderly individuals requiring treatment?

    <p>75/25 mg every 8 hours for up to 5 days</p> Signup and view all the answers

    Which medication combination includes tramadol for pain management?

    <p>Tramacet (37.5 mg tramadol and 325 mg paracetamol)</p> Signup and view all the answers

    What dosing form is ORALLY administered and available for moderate to severe acute pain?

    <p>Orodispersible tablets</p> Signup and view all the answers

    Which of the following conditions is indicated for prophylaxis with verapamil hydrochloride?

    <p>Cluster headache</p> Signup and view all the answers

    Which is a potential side effect associated with the prolonged use of tramadol?

    <p>Respiratory depression</p> Signup and view all the answers

    What is the maximum duration of acute migraine treatment before the risk of medication-overuse headache increases?

    <p>Two days per week</p> Signup and view all the answers

    Which class of medications is NOT typically used to treat acute migraine?

    <p>Prophylactic beta-blockers</p> Signup and view all the answers

    What triggers acute migraine in some women?

    <p>Drop in estrogen levels prior to menstruation</p> Signup and view all the answers

    Which of the following is an essential lifestyle advice for preventing migraine attacks?

    <p>Maintaining adequate hydration</p> Signup and view all the answers

    What type of headache occurs more frequently in women and has severe impacts on daily activities?

    <p>Migraines</p> Signup and view all the answers

    Which type of headache is characterized by unilateral pulsating pain often associated with nausea and vomiting?

    <p>Migraine headache</p> Signup and view all the answers

    What is commonly observed in patients developing medication-overuse headaches?

    <p>Increases in headache frequency and intensity</p> Signup and view all the answers

    Which oral solution ingredient may be present in some headache medications?

    <p>Potassium sorbate</p> Signup and view all the answers

    What is the maximum dosage of triptans that can be taken for acute migraines?

    <p>12.5 mg</p> Signup and view all the answers

    When is the duration for taking prophylactic medications for cluster headache generally considered appropriate?

    <p>Three weeks or longer</p> Signup and view all the answers

    Which of the following is NOT a common side effect associated with 5HT1-receptor agonists?

    <p>Muscle growth</p> Signup and view all the answers

    Which condition is listed as a contraindication for the use of 5HT1-receptor agonists?

    <p>Severe hypertension</p> Signup and view all the answers

    Which side effect is typically NOT seen in patients taking medications for migraines?

    <p>Paralysis</p> Signup and view all the answers

    In what case should the dosage of medications be adjusted to 12.5 mg?

    <p>If creatinine clearance is less than 30 mL/minute</p> Signup and view all the answers

    Which of the following adverse reactions is common for both triptans and 5HT1-receptor agonists?

    <p>Gastrointestinal discomfort</p> Signup and view all the answers

    Which of the following describes a potential side effect of using 5HT1-receptor agonists during pregnancy?

    <p>Preterm labor</p> Signup and view all the answers

    Which common side effect is associated with severe renal impairment in patients on 5HT1-receptor agonists?

    <p>Vision blurred</p> Signup and view all the answers

    What potential consequence should a patient monitor for when taking triptans?

    <p>Symptoms of myocardial ischemia</p> Signup and view all the answers

    Which term describes a potential rare side effect of 5HT1-receptor agonists?

    <p>Shock</p> Signup and view all the answers

    Which of the following conditions would increase the risk of using triptans?

    <p>Coronary vasospasm</p> Signup and view all the answers

    Which side effect could indicate a need to stop using 5HT1-receptor agonists?

    <p>Symptoms of heat, heaviness, pressure, or tightness</p> Signup and view all the answers

    Why should caution be exercised when prescribing 5HT1-receptor agonists to elderly patients?

    <p>Increased likelihood of drug interactions and side effects</p> Signup and view all the answers

    What is the primary mechanism of action for Eptinezumab in migraine prevention?

    <p>Binds to the CGRP receptor</p> Signup and view all the answers

    What is the advised dosing schedule for Fremanezumab after the initial loading dose?

    <p>240 mg for one dose, then 120 mg once a month</p> Signup and view all the answers

    What significant precautions are advised for the use of Eptinezumab during pregnancy?

    <p>Limited safety data available</p> Signup and view all the answers

    Which side effect is NOT commonly associated with Galcanezumab?

    <p>Severe hypertension</p> Signup and view all the answers

    What storage conditions are recommended for both Eptinezumab and Fremanezumab?

    <p>Refrigerated and protected from light</p> Signup and view all the answers

    What is a significant risk associated with Eptinezumab?

    <p>Hypersensitivity reactions</p> Signup and view all the answers

    How should Rimegepant oral lyophilisates be administered?

    <p>Placed on or under the tongue</p> Signup and view all the answers

    What is the purpose of recording the brand name and batch number after administering Eptinezumab?

    <p>To facilitate recall procedures if necessary</p> Signup and view all the answers

    Which of the following is NOT a credible injection site for Aimovig administration?

    <p>Forehead</p> Signup and view all the answers

    What is the standard dosage of Rimegepant for treating acute migraine?

    <p>75 mg once daily</p> Signup and view all the answers

    What should patients be warned about after receiving sedatives and analgesics during outpatient procedures?

    <p>They should not engage in skilled tasks afterwards.</p> Signup and view all the answers

    What common side effect could occur with Rimegepant administration?

    <p>Nausea</p> Signup and view all the answers

    In the case of hepatic impairment, how should the dosage of Temazepam be adjusted?

    <p>Initiate at 5mg daily, adjusting as necessary.</p> Signup and view all the answers

    Which of the following is NOT listed as a contraindication for the use of Temazepam?

    <p>Chronic fatigue syndrome</p> Signup and view all the answers

    What is the advised action regarding breastfeeding after receiving treatments like Eptinezumab?

    <p>Avoid breastfeeding during the first few days after birth</p> Signup and view all the answers

    Which medication is specifically mentioned as not licensed for the management of cluster headaches?

    <p>Ergotamine tartrate</p> Signup and view all the answers

    What is a possible side effect related to the use of Temazepam that patients should be aware of?

    <p>Gastrointestinal discomfort</p> Signup and view all the answers

    What is emphasized regarding the consumption of alcohol while taking medications like Temazepam?

    <p>Alcohol can enhance the sedation effects of medications.</p> Signup and view all the answers

    What dosage adjustment should be considered for elderly patients taking Eptinezumab?

    <p>No adjustment needed</p> Signup and view all the answers

    Which side effect is classified as very rare or rare for the medication described?

    <p>Angina pectoris</p> Signup and view all the answers

    What is the maximum dosage of rizatriptan recommended within 24 hours for patients with mild to moderate impairments?

    <p>2.5 mg</p> Signup and view all the answers

    Which medication is specifically advised against for use during pregnancy unless the potential benefit outweighs the risk?

    <p>Rizatriptan</p> Signup and view all the answers

    What is one of the contraindications for using sumatriptan?

    <p>Severe hypertension</p> Signup and view all the answers

    Which of the following side effects is NOT commonly associated with rizatriptan?

    <p>Epistaxis</p> Signup and view all the answers

    What recommendation is made regarding breastfeeding after treatment with zolmitriptan?

    <p>Withhold breastfeeding for 12 hours</p> Signup and view all the answers

    What is an advised initial dosage for adults taking naratriptan for acute migraine relief?

    <p>10 mg immediately after onset</p> Signup and view all the answers

    Which condition does NOT predispose patients to coronary artery disease?

    <p>Frequent headaches</p> Signup and view all the answers

    What caution should be exercised when prescribing medications to elderly patients according to the content?

    <p>Lower doses generally</p> Signup and view all the answers

    Symptoms that require discontinuation of medication include heat, heaviness, pressure, or which of the following?

    <p>Tightness</p> Signup and view all the answers

    Which side effect is unique to sumatriptan compared to other medications mentioned?

    <p>Flushing</p> Signup and view all the answers

    What adjustment should be made for patients using rizatriptan and propranolol simultaneously?

    <p>Reduce the rizatriptan dose to 5 mg</p> Signup and view all the answers

    For which of the following conditions is zolmitriptan NOT indicated based on the provided information?

    <p>Seizures</p> Signup and view all the answers

    What is the definition of a good response to preventative migraine treatment?

    <p>A 50% reduction in the severity and frequency of migraine attacks</p> Signup and view all the answers

    Which medication is considered a first-line preventative treatment for migraines?

    <p>Propranolol hydrochloride</p> Signup and view all the answers

    Which of the following statements is TRUE regarding sodium valproate?

    <p>It may be used only when the conditions of the Pregnancy Prevention Programme are met.</p> Signup and view all the answers

    What should be monitored after 6-12 months of ongoing prophylaxis for migraines?

    <p>Review of ongoing prophylaxis</p> Signup and view all the answers

    Which combined treatment is less suitable for prescribing due to availability of more effective treatments?

    <p>Isometheptene and paracetamol</p> Signup and view all the answers

    What is a significant consideration for prescribing topiramate?

    <p>The requirement for highly effective contraception during treatment</p> Signup and view all the answers

    Which beta-blocker can be considered if propranolol is unsuitable?

    <p>Bisoprolol fumarate</p> Signup and view all the answers

    What is the advised usage time for preventative migraine treatments before evaluating their effectiveness?

    <p>At least three months</p> Signup and view all the answers

    Isometheptene has potential side effects including all EXCEPT:

    <p>Reduced heart rate</p> Signup and view all the answers

    Which medication combination could lead to severe extrapyramidal effects in certain populations?

    <p>Aspirin with metoclopramide</p> Signup and view all the answers

    Patients who overuse acute migraine treatments like 5HT1-receptor agonists may benefit from which of the following actions?

    <p>Gradual withdrawal of overused medication</p> Signup and view all the answers

    Which of the following is a contraindication for the use of non-steroidal anti-inflammatory drugs (NSAIDs)?

    <p>History of hypersensitivity to NSAIDs</p> Signup and view all the answers

    What is a critical dietary consideration for patients at risk while taking medication like amitriptyline?

    <p>Avoiding caffeine products</p> Signup and view all the answers

    What is the potential impact of long-term use of some NSAIDs on fertility?

    <p>Reduced female fertility, reversible upon cessation</p> Signup and view all the answers

    Which of the following is a recommended maximum daily dose for Zolmitriptan?

    <p>100 mg</p> Signup and view all the answers

    What is the initial recommended dosage for adults experiencing acute migraines with Zolmitriptan?

    <p>2.5 mg</p> Signup and view all the answers

    Which condition is NOT listed as a contraindication for Zolmitriptan?

    <p>Mild asthma</p> Signup and view all the answers

    In the management of neuropathic pain, which of the following medications is NOT a tricyclic antidepressant?

    <p>gabapentin</p> Signup and view all the answers

    When using Zolmitriptan, what is the suggested action if symptoms of heat, heaviness, pressure, or tightness occur?

    <p>Discontinue the medication</p> Signup and view all the answers

    For acute cluster headaches, what is the recommended dosage of Zolmitriptan?

    <p>5 mg</p> Signup and view all the answers

    Who should be particularly cautious when using Zolmitriptan due to potential side effects?

    <p>Elderly individuals</p> Signup and view all the answers

    Which medication is NOT typically recommended for managing trigeminal neuralgia?

    <p>Lidocaine</p> Signup and view all the answers

    What is a common side effect associated with Zolmitriptan when used intranasally?

    <p>Taste alteration</p> Signup and view all the answers

    When should capsaicin be applied for treating localized neuropathic pain?

    <p>Sparingly on the affected area</p> Signup and view all the answers

    What is one of the specific side effects of capsaicin when used topically?

    <p>Intense burning sensation</p> Signup and view all the answers

    What is the advised method for administering zolmitriptan orodispersible tablets?

    <p>Place on the tongue and allow to dissolve</p> Signup and view all the answers

    What is the most effective treatment for severe pain associated with trigeminal neuralgia?

    <p>Carbamazepine</p> Signup and view all the answers

    Which side effect is common with intranasal use of Zolmitriptan?

    <p>Nasal discomfort</p> Signup and view all the answers

    What is the recommended frequency for applying Capsaicin for painful diabetic neuropathy after an initial 8-week period?

    <p>3-4 times a day</p> Signup and view all the answers

    Which of the following precautions should be taken when using Capsaicin?

    <p>Avoid contact with mucous membranes</p> Signup and view all the answers

    What should be monitored during the treatment of patients using Capsaicin?

    <p>Blood pressure</p> Signup and view all the answers

    What is the main reason for avoiding long-term use of hypnotics?

    <p>They often lead to dependency and tolerance</p> Signup and view all the answers

    Which of the following drug types is primarily prescribed for short-term treatment of severe anxiety?

    <p>Benzodiazepines</p> Signup and view all the answers

    Which of the following is NOT a common withdrawal symptom from benzodiazepines?

    <p>Euphoria</p> Signup and view all the answers

    What is advised for elderly patients when prescribing benzodiazepines?

    <p>Benzodiazepines should be avoided due to fall risk</p> Signup and view all the answers

    Which of the following medications is indicated for short-term relief of severe anxiety?

    <p>Lorazepam</p> Signup and view all the answers

    What is the suggested protocol for tapering benzodiazepine doses in long-term users?

    <p>Reduce the dose by 1-2mg every 2-4 weeks</p> Signup and view all the answers

    What is a primary reason beta-adrenoceptor blockers are used in patients with anxiety?

    <p>To address autonomic symptoms like palpitation</p> Signup and view all the answers

    Which medication is preferred for minimizing residual effects during dental procedures?

    <p>Temazepam</p> Signup and view all the answers

    Which benzodiazepine should be avoided during breastfeeding due to its presence in milk?

    <p>Flurazepam</p> Signup and view all the answers

    How long can withdrawal symptoms last for patients who have been on long-term benzodiazepines?

    <p>6-18 months</p> Signup and view all the answers

    For which condition are benzodiazepines NOT recommended as a sole treatment?

    <p>Chronic anxiety</p> Signup and view all the answers

    Which of the following is a caution against the use of certain hypnotics in elderly patients?

    <p>Higher risk of falls and confusion</p> Signup and view all the answers

    What potential side effect does alcohol have when used as a sleep aid?

    <p>Interferes with sleep during the latter part of the night</p> Signup and view all the answers

    What is a potential risk associated with the intramuscular administration of benzodiazepines?

    <p>Respiratory depression</p> Signup and view all the answers

    Which of the following medications is licensed for short-term treatment of insomnia in adults over 55 years?

    <p>Melatonin</p> Signup and view all the answers

    What is the advised initial dosage of flurazepam for adults?

    <p>15-30 mg once daily</p> Signup and view all the answers

    Which of the following is NOT considered a common side effect of benzodiazepines?

    <p>Severe insomnia</p> Signup and view all the answers

    What is considered a major drawback of long-term hypnotic use?

    <p>Tolerance to their effects</p> Signup and view all the answers

    What specific action is recommended when discontinuing benzodiazepines to alleviate withdrawal symptoms?

    <p>Gradual withdrawal</p> Signup and view all the answers

    What paradoxical effect can benzodiazepines produce in some patients?

    <p>Increased hostility</p> Signup and view all the answers

    Which medication acts at specific serotonin (5HT1A) receptors and may take up to 2 weeks to show effects?

    <p>Buspirone hydrochloride</p> Signup and view all the answers

    What is NOT a contraindication for the use of Lormetazepam?

    <p>Severe insomnia</p> Signup and view all the answers

    Which medication is considered less effective than benzodiazepines and poses a higher risk of overdosage?

    <p>Meprobamate</p> Signup and view all the answers

    Which of the following is a potential serious side effect of benzodiazepines?

    <p>Drug abuse</p> Signup and view all the answers

    What is a side effect associated with long-term use of benzodiazepines that impacts cognition?

    <p>Concentration impairment</p> Signup and view all the answers

    Study Notes

    Antipsychotic Drugs

    • Neuroleptic malignant syndrome: Rare but potentially fatal side effect of all antipsychotic drugs. Discontinue the drug and allow symptoms to resolve. Bromocriptine and dantrolene can be used for treatment.
    • Depot injections: May be considered for patients with psychosis or schizophrenia who prefer treatment after an acute episode or where avoiding nonadherence to medication is a clinical priority.
    • Antipsychotic drug side effects:
      • Common or very common: Agitation, amenorrhoea, arrhythmias, constipation, dizziness, drowsiness, dry mouth, erectile dysfunction, fatigue, galactorrhoea, gynaecomastia, hyperglycaemia, hyperprolactinaemia, hypotension, insomnia, leucopenia, movement disorders, muscle rigidity, neutropenia, parkinsonism, postural hypotension, QT interval prolongation, rash, seizure, tremor, urinary retention, vomiting, weight increased, granulocytosis, confusion, embolism and thrombosis, neuroleptic malignant syndrome (discontinue—potentially fatal), and rare or very rare sudden death or withdrawal syndrome.
      • Depot antipsychotics: Overdose, hypotension, hypothermia, sinus tachycardia, and arrhythmias that may complicate poisoning.
      • Developing nervous system: Potential adverse effects, particularly in neonates. Chronic treatment while breastfeeding should be avoided.
    • Monitoring:
      • Weight, blood glucose, HbA1c, and blood lipid concentrations: Baseline, 12 weeks, 1 year, and yearly.
      • Blood pressure: Before starting therapy, at 12 weeks, 1 year, and yearly during treatment and dose titration.
      • Full blood count, urea and electrolytes, and liver function tests: Start of therapy and then yearly thereafter.
      • Prolactin concentration: Start of therapy, at 6 months, and then yearly.
      • Physical health monitoring: At least once per year for patients with schizophrenia.
      • Endocrine function: Regular monitoring in children taking antipsychotics known to increase prolactin levels.
    • Patient and caregiver advice:
      • Avoid direct sunlight.
      • Avoid driving and skilled tasks.
      • Avoid alcohol-induced drowsiness.

    Chlorpromazine Hydrochloride

    • Uses: Managing schizophrenia, psychosis, mania, short-term anxiety, and psychomotor agitation, excitement, and violent behavior.
    • Dosage:
      • Oral: Initial dose of 25 mg three times a day or 75 mg once daily, adjusted according to response. Maintenance doses can be increased up to 1 g daily.
      • Reflex use: 100 mg every 6-8 hours, expressed as chlorpromazine base.
      • Children aged 1-5 years: 500 micrograms/kg every 4-6 hours, with a maximum of 40 mg per day.
      • Children aged 6-11 years: 500 micrograms/kg every 4-6 hours, with a maximum of 75 mg per day.
    • Contra-indications: CNS depression, comatose states, hypothyroidism, and phaeochromocytoma.
    • Side effects: General anxiety, glucose tolerance impaired, mood altered, muscle tone increased, mental health disorders, BNF 85, nervous system disorders, accommodation disorder, angioedema, atrioventricular block, cardiac arrest, eye deposit, eye disorders, gastrointestinal disorders, hepatic disorders, hypertriglyceridaemia, hyponatraemia, photosensitivity reaction, respiratory disorders, sexual dysfunction, SIADH, skin reactions, systemic lupus erythematosus (SLE), temperature regulation disorder, and trismus.
    • Specific side effects: Nasal congestion with intramuscular use.
    • Caution: Children are particularly susceptible to acute dystonic reactions. Caution is advised in severe hepatic failure and renal failure.
    • Monitoring: Maintaining supine patients with blood pressure monitoring for 30 minutes after intramuscular injection.

    Flupentixol

    • Uses: Treating schizophrenia and other psychoses, particularly with apathy and withdrawal but not mania or psychomotor hyperactivity.
    • Dosage:
      • Adults: Maximum dosage of 18 mg per day.
      • Elderly: 0.75-4.5 mg per day.
      • Depression illness: 1 mg daily, increasing to 2 mg after 1 week if necessary.
      • Elderly patients: 500 micrograms daily, with the last dose taken before 4 pm. Maximum dosage is 1.5 mg per day if no response after 1 week.
    • Contra-indications: Circulatory collapse, CNS depression, comatose states, excitable patients, impaired consciousness, and overactive patients.
    • Side effects: Common or very common appetite abnormalities, asthenia, concentration impairment, depression, diarrhea, dyspnea, headache, hyperhidrosis, hypersalivation, myalgia, nervousness, palpitations, sexual dysfunction, skin reactions, urinary disorder, vision disorders, unusual flatulence, hot flush, nausea, oculogyration, photosensitivity reaction, speech disorder, rare or very rare glucose tolerance impaired, jaundice, thrombocytopenia, frequency not known, suicidal behaviors, pregnancy avoidance, breastfeeding, hepatic impairment, renal impairment, and patient and caregiver advice.
    • Administration: Oral suspension or oral solution tablets. Recommended to use in combination with other medications when alternatives are ineffective or not tolerated.
    • Palliative care: Dosage increased to 5-10 mg daily in divided doses.
    • Subcutaneous infusion: Used for adults, with a maximum dose of 2.5-10 mg/24 hours.
    • Schizophrenia and schizoaffective disorder: Given in divided doses, with individual benefit-risk assessed when considering doses above 10 mg daily.

    Haloperidol

    • Uses: Less sedating antipsychotic used for treating delirium in elderly patients.
    • Dosage: Lowest possible dose for the shortest possible time. Any dose increase should be gradual and reviewed frequently.
    • Contra-indications: CNS depression, comatose states, congenital long QT syndrome, dementia with Lewy bodies, history of torsade de pointes, history of ventricular arrhythmia, Parkinson’s disease, progressive supranuclear palsy, QTc-interval prolongation, recent acute myocardial infarction, uncompensated heart failure, and uncorrected hypokalaemia.
    • Generic side-effects: Common or very common depression, eye disorders, headache, hypersalivation, nausea, neuromuscular dysfunction, psychotic disorder, vision disorders, weight decreased, breast abnormalities, dyspnoea, gait abnormality, hepatic disorders, hyperhidrosis, menstrual cycle irregularities, muscle complaints, musculoskeletal stiffness, oedema, photosensitivity reaction, restlessness, sexual dysfunction, skin reactions, temperature regulation disorders, hypoglycaemia, respiratory disorders, SIADH, trismus, frequency not known, hypersensitivity vasculitis, pantopenia, rhabdomyolysis, thrombocytopenia, and severe cutaneous adverse reactions (SCARs).
    • Specific side-effects: Oral use angioedema, parenteral use hypertension, and severe cutaneous adverse reactions (SCARs).
    • Caution: Halve initial doses in pregnancy and then adjust if necessary with smaller increments and at longer intervals. Use with caution in renal impairment, considering lower initial dose in severe impairment and then adjusting if necessary with smaller increments and at longer intervals.
    • Monitoring: Electrolytes before and periodically during treatment. Baseline ECG recommended before treatment initiation, further ECGs must be assessed individually. Continuous ECG monitoring recommended for repeated intramuscular doses, serial ECG monitoring may be used if continuous ECG monitoring is not available.

    Loxapine

    • Uses: Rapid control of mild-to-moderate agitation in patients with schizophrenia or bipolar disorder.
    • Dosage: Adults should take 9.1 mg as a single dose, followed by 9.1 mg after 2 hours if required, or alternatively 4.5 mg as a single dose, followed by 4.5 mg after 2 hours if required. Lower doses may be given if more appropriate or if the higher dose is not previously tolerated.
    • Contra-indications: Acute respiratory symptoms, asthma, cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, dehydration, hypotension, elderly patients, and hypovolaemia.
    • Caution: Bronchodilator treatment should be available for possible severe respiratory side-effects (bronchospasm), history of extrapyramidal symptoms, and risk factors for hypoventilation.
    • Side effects: Common or very common taste altered, throat irritation, uncommon bronchospasm, oculogyration, restlessness, frequency not known, dry eye, hypertension, syncope, and vision blurred.
    • Pregnancy: Only if potential benefit outweighs risk.
    • Monitoring: Observe patients during the first hour after each dose for signs and symptoms of bronchospasm.
    • Administration: Remove the pull-tab and wait for green light to turn on, instruct patient to inhale through mouthpiece and hold breath briefly.

    Adasuve® 4.5mg inhalation powder

    • Uses: Managing schizophrenia and psychoses.
    • Dosage: Adults should take 75 mg daily in divided doses, increasing in steps of 25 mg every week until the maximum daily dose is reached. Elderly individuals should take 15-30 mg daily in divided doses, increasing in steps of 25 mg every week until the maximum daily dose is reached.

    Pericyazine

    • Uses: Short-term adjunctive management of severe anxiety, psychomotor agitation, and violent or dangerously impulsive behavior.
    • Dosage: Adults should take 15-30 mg daily in two divided doses, adjusted according to response, larger dose to be taken at bedtime. Elderly individuals should take 5-10 mg daily in two divided doses, adjusted according to response, larger dose to be taken at bedtime.
    • Side effects: Atrioventricular block, cardiac arrest, consciousness impaired, contact dermatitis, glucose tolerance impaired, hepatic disorders, hyperthermia, nasal congestion, priapism, respiratory depression, hepatotoxicity.
    • Caution: Renal impairment due to the risk of accumulation.
    • Medicinal forms: Oral suspension, oral solution, tablets, and tablets.

    Pimozide

    • Uses: Monosymptomatic hypochondriacal psychosis and paranoid psychosis.
    • Side effects: Decreased appetite, depression, headache, hyperhidrosis, hypersalivation, restlessness, sebaceous gland overactivity, urinary disorders, vision blurred, dysarthria, face oedema, muscle spasms, oculogyric crisis, skin reactions, and frequency not known.
    • Monitoring: Annual ECG following reports of sudden unexplained death.
    • Caution: Do not give with other antipsychotic drugs, tricyclic antidepressants, or drugs that prolong the QT interval.

    Orap (Eumedica Pharma Ltd)

    • Uses: Treating schizophrenia and other psychoses.
    • Dosage:
      • Schizophrenia: Adults should take 12.5 mg twice daily for 7 days, adjusted at intervals of 4-7 days according to response.
      • Deep intramuscular injection: Adults should take 12.5-25 mg 2–3 times a day.
      • Anxiety: Adults should take 15-20 mg daily in divided doses; maximum 40 mg per day.
      • Nausea and vomiting: Adults should take 20 mg initially, then 10 mg after 2 hours.
      • Deep intramuscular injection: Adults should take 12.5 mg as required, followed by an oral dose.
      • Lymphinthine disorders: Adults should take 5-10 mg twice daily, gradually increasing the dose to 5-10 mg daily.
      • Acute migraine: Adults should take 10 mg for one dose taken as soon as migraine symptoms develop.
    • Caution: Avoid oral route in children under 10 kg. CNS depression, comatose states, and phaeochromocytoma.
    • Side effects: Glucose tolerance impaired, hyponatremia, SIADH, photosensitivity reaction, blood disorder, hepatic disorders, and acute dystonias.
    • Manufacturer advice: Hepetic impairment and renal impairment, start with small doses in severe renal impairment due to increased cerebral sensitivity.

    Prochlorperazine

    • Uses: Schizophrenia, anxiety, and acute migraines.
    • Dosage: Adults should take 12.5 mg twice daily for 7 days, adjusted at intervals of 4-7 days according to response. For deep intramuscular injection, adults should take 12.5-25 mg 2–3 times a day. For anxiety, adults should take 15-20 mg daily in divided doses; maximum 40 mg per day. For nausea and vomiting, adults should take 20 mg initially, then 10 mg after 2 hours. For deep intramuscular injection, adults should take 12.5 mg as required, followed by an oral dose. Prevention and treatment of nausea and vomiting are recommended for children aged 1-11 years, 12-17 years, and children aged 2-4 years. For lymphinthine disorders, adults should take 5-10 mg twice daily, gradually increasing the dose to 5-10 mg daily. Acute migraine is also advised for adults, with 10 mg for one dose taken as soon as migraine symptoms develop.
    • Contra-indications: Avoid oral route in children under 10 kg. CNS depression, comatose states, and phaeochromocytoma.
    • Cautions: Glucose tolerance impaired, hyponatremia, SIADH, photosensitivity reaction, blood disorder, hepatic disorders, and acute dystonias.
    • Manufacturer advice: Hepetic impairment and renal impairment, start with small doses in severe renal impairment due to increased cerebral sensitivity.

    Prochlorperazine buccal tablets

    • Manufacturer recommendation: Place them high between the upper lip and gum and leave them to dissolve. Patients or carers should be given advice on how to administer prochlorperazine buccal tablets.
    • Licensing: There can be variation in the licensing of different medicines containing the same drug.
    • Uses: Schizophrenia with predominantly negative symptoms.
    • Dosage: Adults should take 200-400 mg twice daily, and elderly patients should take a lower initial dose. Schizophrenia with mainly positive symptoms should be given 200-400 mg twice daily, with elderly patients taking a lower initial dose.

    Sulpiride

    • Dosage: Adults should take 200-400 mg twice daily, elderly patients should take a lower initial dose.
    • Monitoring: MHRA advises monitoring blood concentrations after fatal cases involving toxicity of clozapine and other antipsychotic medicines. Monitoring blood concentration may be helpful in certain circumstances, such as patients presenting symptoms suggestive of toxicity or when concomitant medicines may interact to increase blood concentration of sulpiride.
    • Contra-indications: CNS depression, comatose states, and phaeochromocytoma.
    • Cautions: Aggressive patients, agitated patients, and excited patients.
    • Side effects: Common or very common breast abnormalities, hypersalivation, muscle tone increased, organasm abnormal, rare or very rare oculogyric crisis, cardiac arrest, dyspnoea, hyponatraemia, SIADH, trismus, and urticaria.
    • Blood pressure: Sulpiride does not affect blood pressure to the same extent as other antipsychotic drugs, so blood pressure monitoring is not mandatory.

    Trifluoperazine

    • Antipsychotic drug
    • Does not affect blood pressure as much as other antipsychotics, so blood pressure monitoring is not mandatory
    • Available in oral solution and tablets
    • Dosages range from 20-30 mg daily in divided doses, increasing if necessary up to 150 mg daily
    • Elderly patients should use an elderly dose of 5-15 mg daily in divided doses, increasing if necessary up to 150 mg daily
    • Contra-indications include apathetic states, CNS depression, comatose states, phaeochromocytoma, and withdrawal states
    • Cautions include hyperthyroidism and hypothyroidism

    Zuclopenthixol

    • Side effects include anxiety, appetite abnormality, asthenia, concentration impaired, depression, diarrhea, dyspnea, eye disorders, fever, flatulence, gait abnormality, gastrointestinal discomfort, glucose tolerance impaired, headaches, hepatic disorders, hot flush, hyperacusia, hyperhidrosis, hyperlipidaemia, hypersalivation, hyperothermia, malaise, memory loss, myalgia, nasal congestion, nausea, neuromuscular dysfunction, pain, palpitations, paraesthesia, reflexes increased, seborrhoea, sexual dysfunction, skin reactions, sleep disorders, speech disorders, syncope, thirst, thrombocytopenia, tinnitus, urinary disorders, vertigo, vision disorders, vulvovaginal dryness, weight decreased, and withdrawal syndrome
    • Manufacturer advises caution in managing atopic dermatitis, mania, and short-term exacerbation of chronic psychosis
    • For adults, 50-150 mg is recommended, followed by 50-150 mg after 2-3 days if required
    • The maximum cumulative dose is 400mg in 2 weeks and 4 injections, with a maximum duration of treatment of 2 weeks
    • Elderly patients should take 50-100 mg, then 50-100 mg after 2-3 days if required
    • Injection solutions for Zuclopenthixol acetate include Clopixol Acuphase (Lundbeck Ltd), which is 50 mg per 1 ml

    Flupentixol

    • Manufacturer advises caution in prescribing and administering Zuclopenthixol acetate and decanoate, and caution in renal failure
    • Solution for injection is Depixol (Lundbeck Ltd), which offers Flupentixol decanoate 20 mg per 1 ml, Depixol 40mg/2ml solution for injection ampoules, Flupentixol decanoate 100 mg per 1 ml, Depixol Conc 100mg/1ml solution for injection ampoules, Flupentixol decanoate 200 mg per 1 ml, Depixol Low Volume 200mg/1ml solution for injection ampoules, and Psytixol (Viatris UK Healthcare Ltd)
    • Maintenance in schizophrenia and schizoaffective disorder is recommended by deep intramuscular injection
    • Adults should start with 25-150 mg every 4 weeks, adjusted in steps up to 50 mg every 4 weeks if required
    • The usual maintenance dose is 50-200 mg every 4 weeks, administered into gluteal muscle
    • Elderly patients should start with 12.5-25 mg every 4 weeks, increased if necessary to 25-75 mg every 4 weeks, adjusted dosing intervals, and doses above 75 mg every 4 weeks only be considered in patients who have tolerated higher doses

    Haloperidol

    • Less sedating antipsychotic used for maintenance treatment in schizophrenia and paranoid psychoses
    • Contra-indications include CNS depression, comatose states, congenital long QT syndrome, dementia with Lewy bodies, and other conditions
    • Cautions include Bradycardia, electrolyte disturbances, family history of QTc interval prolongation, heavy alcohol exposure, hyperthyroidism, hypotension (including orthostatic hypotension), prolactin-dependent tumors, prolactinaemia, and risk factors for stroke
    • Side effects include common or very common depression, hypersalivation, sexual dysfunction, eye disorders, headache, neuromuscular dysfunction, vision disorders, angioedema, breast abnormalities, cardiac arrest, dyspnoea, gait abnormality, hepatic disorders, hyperhidrosis, hypersensitivity vasculitis, hypoglycaemia, menstrual cycle irregularities, muscle complaints, musculoskeletal stiffness, nausea, oedema, pantopenia, photosensitivity reaction, psychotic disorder, respiratory disorders, restlessness, rhabdomyolysis, SIADH, skin reactions, temperature regulation disorders, thrombocytopenia, trismus, weight decrease, and more
    • Manufacturers generally advise not more than 2-3mL of oily injection should be administered at any one site, using correct injection technique (including use of the z-track technique) and rotating injection sites
    • Indications and dose for haloperidol include a test dose of 100 mg for adults, followed by 200-500 mg every 1-4 weeks, adjusted according to response
    • Elderly patients should use a quarter to half of their usual starting dose

    Amisulpride

    • Second-generation antipsychotic, a selective dopamine receptor antagonist with high affinity for mesolimbic D2 and D3 receptors
    • Indications and doses include 400-800 mg daily in 2 divided doses, adjusted according to response; maximum 1.2 g per day for acute psychotic episodes in schizophrenia and 50-300 mg daily for schizophrenia with predominantly negative symptoms
    • Pregnancy and breast feeding should be avoided
    • Renal impairment should be monitored if creatinine clearance is less than 10 mL/minute
    • The manufacturer advises halving dose if creatinine clearance is 30-60 mL/minute and using one-third dose if clearance is 10-30 mL/minute
    • Blood pressure monitoring is not mandatory for this drug

    Aripiprazole

    • Dopamine D2 partial agonist with weak 5-HT1a partial agonism and 5-HT2A receptor antagonism
    • In schizophrenia, adults should take 10-15 mg once daily, with a usual dose of 15 mg once daily
    • The medication is used to control agitation and disturbed behavior in schizophrenia and mania
    • It is administered orally, with a dosage of 15 mg once daily, increasing if necessary up to 30 mg once daily
    • In intramuscular injections, the dosage is adjusted based on the concurrent use of potent inducers of CYP3A4 or inhibitors of CYP3A4 or CYP2D6
    • The medication is also used for maintenance of schizophrenia in patients stabilised with oral aripiprazole
    • Initial injections are 300 mg every month, with a minimum of 26 days between injections
    • Treatment with the prescribed daily dose of oral aripiprazole should be continued for 14 consecutive days after the first injection
    • Maintenance is 400 mg every month, with a minimum of 26 days between injections
    • The medication should not be confused with depot preparations, which are usually used in the community or clinics for maintenance treatment
    • The MHRA advises monitoring blood concentrations for toxicity following fatal cases involving clozapine and other antipsychotic medicines
    • Cautions include cerebrovascular disease, elderly individuals, risk of aspiration pneumonia, and interactions with second-generation antipsychotics
    • Aripiprazole has various side effects, including anxiety, appetite abnormalities, diabetes mellitus, gastrointestinal discomfort, headaches, hyperalivation, musculoskeletal stiffness, nausea, vision disorders, weight decreased, and more
    • It also has uncommon side effects such as alopecia, depression, diarrhea, hiccups, hypertension, sexual dysfunction, suicidal behaviors, and thrombocytopenia
    • Specific side effects include altered smell sensation, anemia, asthenia, behavior abnormality, breast tenderness, chest discomfort, cough, drooling, dyslipidaemia, eye pain, fever, gait abnormality, gastrointestinal disorders, glycosuria, hyperinsulinaemia, joint disorders, muscle complaints, muscle tone increased, nephrolithiasis, oculogyric crisis, pain, skin reactions, sleep disorder, taste altered, thirst, vulvovaginal dryness, and frequency not known
    • Pregnancy use is recommended only if potential benefit outweighs risk
    • Breast feeding is advised to avoid
    • Hepatic impairment is advised with caution
    • Aripiprazole does not affect blood pressure to the same extent as other antipsychotic drugs, so blood pressure monitoring is not mandatory
    • Directions for administration include placing orodispersible tablets on the tongue and allowing them to dissolve or be dispersed in water and swallowed
    • The manufacturer provides a user manual for healthcare professionals
    • Patients or carers should be given advice on how to administer aripiprazole orodispersible tablets
    • National funding/access decisions for Aripiprazole include the Scottish Medicines Consortium (SMC) decision for maintenance treatment of schizophrenia in adult patients stabilised with oral aripiprazole
    • The medication is available in various forms, including oral solution, tablet, and injection solutions
    • The drug's excipients may include Sulfobutylether beta cyclodextrin sodium, Disodium edetate, hydroxybenzoates (parabens), propylene glycol, and sucrose
    • the oral solution may contain Disodium edetate, hydroxybenzoates (parabens), propylene glycol, and sucrose

    Caripiprazole

    • Medication used to treat schizophrenia in adults, with various forms available from special-order manufacturers
    • The drug's side effects include anxiety, appetite abnormalities, dyslipidemia, eye disorders, and liver impairment
    • National funding/access decisions for Caripiprazole (Reagila®) for the treatment of schizophrenia in adult patients are available on the Scottish Medicines Consortium (SMC) website
    • National funding/access decisions for Caripiprazole (Reagila®) for the treatment of schizophrenia in adult patients are available on the Scottish Medicines Consortium (SMC) website
    • The All Wales Medicines Strategy Group (AWMSG) has recommended Caripiprazole (Reagila®) for the treatment of schizophrenia in adult patients (May 2022) with restrictions
    • Caripiprazole (as Cariprazine hydrochloride) is available in capsules, with Reagila (Recordati Pharmaceuticals Ltd) offering different dosages
    • The drug's use in clinical trials has been limited by its potential side effects, including gastrointestinal issues, hepatitis, and liver impairment

    Clozapine

    • Dopamine D1, dopamine D2, 5-HT2A, alpha1-adrenoceptor, and muscarinic-receptor antagonist used to treat schizophrenia in patients unresponsive to conventional antipsychotic drugs
    • It is recommended for adults aged 18-59 years and older, with dosages increasing gradually over 14-21 days
    • For adults 60 years and over, the dosage is increased to 25-37.5 mg daily, with a maximum of 900mg per day
    • Clozapine has been associated with varying degrees of impairment of intestinal peristalsis, and patients and their carers should seek immediate medical advice before taking the next dose of clozapine if constipation develops
    • The MHRA/CHM advice recommends monitoring blood concentrations for toxicity in certain clinical situations, such as when a patient stops smoking or switches to an e-cigarette, concomitant medicines may interact to increase blood clozapine levels, a patient has pneumonia or other serious infection, reduced clozapine metabolism is suspected, or toxicity is suspected
    • Clozapine blood concentration monitoring should be carried out in addition to the required blood tests to manage the risk of agranulocytosis
    • Contra-indications include alcoholic and toxic psychoses, bone-marrow disorders, coma, drug intoxication, history of agranulocytosis, history of circulatory collapse, history of neutropenia, paralytic ileus, severe cardiac disorders (e.g.myocarditis), severe CNS depression, and uncontrolled epilepsy

    Clozapine

    • Used for psychosis in Parkinson's disease in children aged 16 years and over.
    • Cautions: Age over 60 years, prostatic hypertrophy, susceptibility to angle-closure glaucoma, intestinal obstruction (including impaired peristalsis, constipation, faecal impaction, and paralytic ileus), and patients taking drugs that cause constipation or those with colonic disease or lower abdominal surgery.
    • Side effects: Decreased appetite, fever, headache, hypertension, leucocytosis, nausea, oral disorders, speech impairment, sweating abnormal, syncope, temperature regulation disorders, urinary disorders, vision blurred, uncommon falls, anemia, cardiac arrest, cardiac inflammation, cardiomyopathy, circulatory collapse, delirium, diabetes mellitus, dyslipidaemia, dysphagia, gastrointestinal disorders, glucose tolerance impaired, hepatic disorders, increased risk of infection, intestinal obstruction (including fatal cases), ketoacidosis, nephritis, tubulointerstitial, obsessive-compulsive disorder, pancreatitis, pericardial effusion, respiratory disorders, restlessness, sexual dysfunction, skin reactions, sleep apnoea, thrombocytopenia, thrombocytosis.
    • Pregnancy: Use with caution.
    • Breastfeeding: Avoid.
    • Monitoring requirements: Leucocyte and differential blood counts, blood clozapine concentration, blood lipids and weight, and fasting blood glucose.
    • Administration: Oral suspension needs 90 seconds shaking for dispensing if visually settled, otherwise 10 seconds before use. Orodispersible tablets dissolve on the tongue.

    Lurasidone

    • Used to treat schizophrenia in adults and adolescents aged 13 years and over.
    • Available as oral suspension, oral solution, and tablets.
    • Action: Dopamine D2, 5-HT2A, 5-HT7, alpha2A- and alpha2C-adrenoceptor antagonist; partial agonist at 5-HT1a receptors.
    • Dosage: Adults start with 37 mg once daily, increased up to 148 mg once daily. Increase to 18.5 mg once daily with moderate CYP3A4 inhibitors; 74 mg once daily in severe impairment.
    • Cautions: High doses in elderly may cause QT interval prolongation. Moderate to severe impairment poses risk of increased exposure. Avoid severe impairment.
    • Side effects: Anxiety, drooling, gastrointestinal discomfort, hypersensitivity, musculoskeletal stiffness, nausea, oculogyric crisis, oral disorders, pain, pruritus, psychiatric disorders, sleep disorders, decreased appetite, dysarthria, dysuria, gait abnormality, gastrointestinal disorders, hot flush, hyperhidrosis, hypertension, hyponatraemia, joint stiffness, myalgia, nasopharyngitis, vision blurred, rare or very rare angioedema, eosinophilia, rhabdomyolysis, anemia, angina pectoris, atrioventricular block, breast abnormalities, diarrhea, dysmenorrhoea, dysphagia, renal failure, Stevens-Johnson syndrome, suicidal behavior, and vertigo.
    • Pregnancy: Use only if potential benefit outweighs risk.
    • Breastfeeding: Use only if potential benefit outweighs risk.

    Olanzapine

    • Dopamine D1, D2, D4, 5-HT2, histamine-1, and muscarinic-receptor antagonist.
    • Used in combination therapy for schizophrenia and bipolar disorder.
    • Dosage: Adults: 10 mg daily adjusted, or 5-20 mg daily (doses greater than 10 mg reassessed). Monotherapy: 15 mg daily adjusted, or 5-20 mg daily (doses greater than 15 mg reassessed). Mania: 15 mg daily adjusted, or 15 mg daily (doses greater than 15 mg reassessed).
    • Intramuscular use Cautions: Acute myocardial infarction, bradycardia, recent heart surgery, severe hypotension, sick sinus syndrome, unstable angina, bone-marrow depression, hypereosinophilic disorders, low leucocyte count, low neutrophil count, myeloproliferative disease, paralytic ileus, CNS and respiratory depression. Monitor blood pressure, pulse, and respiratory rate for at least 4 hours after intraamuscular injection, especially if a benzodiazepine or another antipsychotic is administered.
    • Side effects: General: Anticholinergic syndrome, appetite increased, arthralgia, asthenia, eosinophilia, fever, glycosuria, oedema, sexual dysfunction, abdominal distension, alopecia, breast enlargement, diabetes mellitus, dysarthria, epistaxis, memory loss, photosensitivity reaction, urinary disorders, hepatic disorders. Specific: Dyslipidemia, hypersomnia, hypoventilation, diabetic coma, ketoacidosis, oculogyration, withdrawal syndrome, cardiovascular event, erythema, fall, gait abnormal, hallucinations, and pneumonia.
    • Pregnancy: Use only if potential benefit outweighs risk. Neonatal lethargy, tremor, and hypertonia reported in third trimester use.
    • Breastfeeding: Avoid.
    • Cautions: Prevent hepatic impairment and dose adjustments.
    • Monitoring requirements: Measure blood lipids and weight at baseline, every 3 months with antipsychotic drugs, and every 4-6 months with fasting blood glucose. Test fasting blood glucose at baseline, after one month's treatment, then every 4-6 months.
    • Important considerations: Ensure correct preparation is used for intramuscular injection (typically used in hospitals for rapid control of acute episodes, not depot preparations for maintenance). Orodispersible tablets are available. Medicinal forms vary between different medicines containing the same drug.

    Paliperidone

    • Metabolite of risperidone.
    • Used for schizophrenia and other psychotic or manic symptoms.
    • Dosage: Adults: 3-12 mg daily. Maintenance: Adjust based on response.
    • Cautions: Cataract surgery, dementia with Lewy bodies, elderly patients with dementia, predisposition to gastrointestinal obstruction, and prolactin-dependent tumors. Reduce dose gradually when transferring from oral to depot therapy.
    • Side effects: Anxiety, appetite abnormalities, asthenia, cardiac conduction disorders, cough, depression, diarrhea, fever, gastrointestinal discomfort, headache, hypertension, increased risk of infection, joint disorders, laryngeal pain, mood altered, nasal congestion, nausea, oral disorders, pain, skin reactions, vision disorders, alopecia, anemia, breast abnormalities, chest discomfort, chills, conjunctivitis, cystitis, dry eye dysarthria, dysphagia, dyspnoea, ear pain, epistaxis, fall, gait abnormal, gastrointestinal disorders, generalised tonic-clonic seizure, hypoglycaemia, induration, malaise, menstrual cycle irregularities, muscle spasms, muscle weakness, oedema, palpitations, respiratory disorders, sensation abnormal, sexual dysfunction, sleep disorders, syncope, taste altered, thirst, thrombocytopenia, tinnitus, urinary disorders, vertigo, rare or very rare angioedema, cerebrovascular insufficiency, coma, consciousness impaired, dandruff, diabetic ketoacidosis, dysphonia, eye disorders, flushing, glaucoma, hypothermia, ischaemia, jaundice, pancreatitis, polydipsia, posture abnormal, rhabdomyolysis, SIADH, sleep apnoea, vaginal discharge, water intoxication, withdrawal syndrome, injection site necrosis.
    • Pregnancy: Use only if potential benefit outweighs risk. Withdraw gradually if discontinuation is necessary. Consider long-acting nature of formulation, as paliperidone can be detected in plasma up to 18 months after a single dose.
    • Cautions: Severe impairment: Caution advised. Intramuscular use: Dose should be adjusted and stabilized with once-monthly injectable paliperidone before switching to three-monthly injectable paliperidone.
    • Administration: Intramuscular: Correct technique (z-track) and rotation of injection sites. Oral: Take with breakfast or an empty stomach.
    • Missed doses: Can occur with intramuscular use.
    • Available forms: Prolonged-release suspension for injection, modified-release tablets, suspension for injection.

    Quetiapine

    • Dopamine D1, dopamine D2, 5-HT2, alpha1-adrenoceptor, and histamine-1 receptor antagonist.
    • Used for schizophrenia, bipolar disorder, and depression.
    • Dosage: Schizophrenia: 25 mg twice daily for day 1, 50 mg twice daily for day 2, 100 mg twice daily for day 3, 150 mg twice daily for day 4, adjusted according to response. Usual dose: 300-450 mg daily in two divided doses. Elderly: Slower titration rate and lower daily dose. Modified-release: Maximum 600 mg once daily under specialist supervision. Elderly: Start with 50 mg once daily, adjusted in steps of 50 mg daily.
    • Dosage: Bipolar disorder: Mania: 50 mg twice daily for day 1, then 100 mg twice daily for day 2, 150 mg twice daily for day 3, 200 mg twice daily for day 4, adjusted according to response. Usual dose: 400-800 mg daily in two divided doses. Elderly: Slower titration rate and lower daily dose. Prevention of mania and depression: Continue at effective treatment dose and adjust to lowest effective dose.
    • Dosage: Major depression: Modified-release: 50 mg once daily for 2 days, then 150 mg once daily for 2 days, adjusted according to response. Elderly: Start with 50 mg once daily for 3 days, then increase if necessary to 100 mg once daily for 4 days, then adjust in steps of 50 mg, adjusted according to response.
    • Cautions: Cerebrovascular disease, elderly patients, history or risk factors for sleep apnoea, patients at risk of aspiration, pneumonia, and treatment of depression in patients under 25 years (increased risk of suicide).
    • Side effects: Increased appetite, asthenia, dyspepsia, dyspnoea, fever, headache, irritability, palpitations, peripheral oedema, rhinitis, sleep disorders, suicidal behavior, syncope, vision blurred, withdrawal syndrome, uncommon anemia, diabetes mellitus, dysphagia, hypothyroidism, sexual dysfunction, skin reactions, thrombocytopenia, rare or very rare angioedema, breast swelling, gastrointestinal disorders, hepatic disorders, hypothermia, menstrual disorder, metabolic syndrome, pancreatitis, rhabdomyolysis, severe cutaneous adverse reactions (SCARs), and SIADH.
    • Pregnancy: Use only if potential benefit outweighs risk.
    • Breastfeeding: Avoid.
    • Dose adjustments: Immediate-release tablets: Initially 25 mg daily, increased daily in steps of 25–50 mg. Modified-release tablets: Initially 50mg daily, increased daily in steps of 50 mg.

    Risperidone

    • Dopamine D2, 5-HT2A, alpha1-adrenoceptor, and histamine-1 receptor antagonist.
    • Used for treating acute and chronic psychosis.
    • Dosage: Adults, elderly, and patients with moderate to severe Alzheimer's dementia. For short-term treatment of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to nonpharmacological interventions and when there is a risk of harm to self or others, start with 250 micrograms twice daily, then increased in steps of 250 micrograms twice a day on alternate days.
    • Cautions: May be confused with ropinirole; ensure correct drug is prescribed and dispensed. Monitor blood concentrations for toxicity in cases suggestive of toxicity, or when concomitant medicines may interact to increase blood concentration of risperidone.

    Risperidone

    • Risperidone is used to treat mental health disorders and nervous system disorders.
    • Available forms include oral solution, tablet, powder and solvent for suspension for injection, orodispersible tablets.
    • Common/Very Common side effects: anemia, anxiety, appetite abnormality, asthenia, chest discomfort, conjunctivitis, cough, depression, diarrhea, dyspnea, epistaxis, fall, fever, gastrointestinal discomfort, headache, hypertension, increased risk of infection, joint disorders, laryngeal pain, muscle spasms, nasal congestion, nausea, edema, oral disorders, pain, sexual dysfunction, skin reactions, sleep disorders, urinary disorders, vision disorders, weight decreased, alopecia, breast abnormalities, cardiac conduction disorders, cerebrovascular insufficiency, chills, coma, concentration impaired, consciousness impaired, cystitis, diabetes mellitus, dry eye, dysarthria, dysphagia, dysphonia, ear pain, eye disorders, feeling abnormal, flushing, gait abnormal, gastrointestinal disorders, induration, malaise, menstrual cycle irregularities, mood altered, muscle weakness, palpitations, polydipsia, posture abnormal, procedural pain, respiratory disorders, sensation abnormal, syncope, taste altered, thirst, thrombocytopenia, tinnitus, vaginal discharge, vertigo.
    • Rare/Very Rare side effects: angioedema, catatonia, dandruff, diabetic ketoacidosis, eyelid crusting, glaucoma, hypoglycemia, hypothermia, jaundice, pancreatitis, peripheral coldness, rhabdomyolysis, SIADH, sleep apnea, water intoxication, withdrawal syndrome.
    • Frequency Not Known: cardiac arrest, severe cutaneous adverse reactions (SCARs).
    • Pregnancy: Use only if potential benefit outweighs risk.
    • Breastfeeding: Use only if potential benefit outweighs risk.
    • Hepatic Impairment: Dose adjustments should be made with oral use, with dose reduction to half the usual dose and slower dose titration.
    • Risperidone CONSTA® INJECTION: Dose adjustments should be made with oral use, with initial and subsequent doses halved, with slower dose titration.
    • Storage: Store in refrigerator (2-8°C) and protect from light. Can also be stored at room temperature (below 25°C) for up to 7 days.
    • Administration:
      • Oral: Tablets should be placed on the tongue and allowed to dissolve before swallowing. Oral liquid can be diluted with non-alcoholic drinks, except tea.
      • Intramuscular: Use correct injection technique (including the z-track technique) and rotate injection sites.

    Olanzapine

    • Common/Very Common side effects: anticholinergic syndrome, appetite increased, arthralgia, asthenia, eosinophilia, fever, glycosuria, edema, sexual dysfunction.
    • Uncommon side effects: abdominal distension, alopecia, breast enlargement, diabetes mellitus, diabetic coma, dysarthria, epistaxis, ketoacidosis, memory loss, oculogyration, photosensitivity reaction, urinary disorders.
    • Rare/Very Rare side effects: drug reaction with eosinophilia and systemic symptoms (DRESS), hepatic disorders, hypothermia, pancreatitis, rhabdomyolysis, thrombocytopenia.
    • Frequency Not Known: erythema, gait abnormality, increased risk of fall, pneumonia, visual hallucinations.
    • Pregnancy: Use only if potential benefit outweighs risk.
    • Breastfeeding: Avoid due to presence in milk.
    • Renal Impairment: Manufacturer advises caution and an initial dose of 150mg every 4 weeks for renal impairment.
    • Monitoring: Observe patient for at least 3 hours after injection, monitor blood lipids and weight at baseline, three months, and yearly with antipsychotic drugs, and fasting blood glucose at baseline, four to six months, and yearly.
    • Administration: Use the correct injection technique (including the use of the z-track technique) and rotate injection sites.

    Cerebral Palsy

    • A group of permanent, non-progressive abnormalities in the developing fetal or neonatal brain.
    • Leads to movement and posture disorders, causing activity limitation and functional impact.
    • Not curable and affects participation and quality of life, particularly eating, drinking, comfort, and sleep.
    • Increasing number of adults living with Cerebral Palsy, with a wide range of abilities from full independence to requiring 24-hour care.

    Motor Neurone Disease

    • A neurodegenerative condition affecting the brain and spinal cord.
    • Degeneration of motor neurons leads to progressive muscle weakness, resulting in symptoms such as muscle cramps, wasting and stiffness, loss of dexterity, reduced respiratory function, and cognitive dysfunction.
    • The most common form is amyotrophic lateral sclerosis (ALS).
    • Patients suspected of having developed motor neurone disease should be referred to a neurologist immediately.
    • Treatment focuses on maintaining functional ability and managing symptoms.

    Treatment of Cerebral Palsy & Motor Neurone Disease

    • Non-drug Treatment:

      • Nutrition
      • Psychosocial support
      • Physiotherapy
      • Exercise programs
      • Use of special equipment or mobility aids.

    • Drug Treatment:

      • Muscle Cramps: Quinine, Baclofen
      • Muscle Stiffness: Tizanidine, Dantrolene sodium, Gabapentin
      • Reduced Respiratory Function: Dantrolene sodium
      • Severe Spasticity: Specialist referral
      • Respiratory Symptoms: Treatment before considering other options. Opioids or benzodiazepines can be used for breathlessness exacerbated by anxiety. Non-invasive ventilation should be considered for patients with respiratory impairment.
      • Amyotrophic Lateral Sclerosis: Riluzole can be used to extend life or extend time to mechanical ventilation.

    Dystonias and Other Involuntary Movements

    - Treated with various drugs.

    Tetrabenazine

    • Used to control movement disorders in Huntington's chorea and related disorders.
    • Can be prescribed for the treatment of tardive dyskinesia if switching or withdrawing the causative antipsychotic drug is not effective.
    • Dosage:
      • Huntington's Chorea: 25 mg three times a day, increased by 25 mg every 3-4 days, maximum 200 mg per day.
      • Tardive Dyskinesia: 12.5 mg daily, gradually increased according to response.
    • Contraindications: Depression, Parkinsonism, pheochromocytoma, prolactin-dependent tumors.
    • Pregnancy: Avoid due to toxicity in animal studies.
    • Breastfeeding: Avoid.
    • Hepatic Impairment: Dosage adjustments are advised, with an initial dose reduction of 50% and slower dose titration in mild to moderate impairment.

    Botulinum Toxin Type A

    • Neurotoxic substance used for various purposes, including:

      • Hand and wrist disability due to upper limb spasticity associated with stroke.
      • Foot and ankle disability due to lower limb spasticity associated with stroke.
      • Blepharospasm.
      • Hemifacial spasm.
      • Spasmodic torticollis.
      • Severe hyperhidrosis of the axillae.
      • Prophylaxis of headaches in chronic migraine.
      • Temporary improvement of moderate to severe upper facial lines in adults under 65 years.
      • Management of bladder dysfunctions.
      • Chronic sialorrhoea due to neurological disorders.

    • Contraindications:

      • Acute urinary retention.
      • Catheterization difficulties.
      • Infection at the injection site.
      • Presence of bladder calculi.
      • Urinary tract infection.

    • Cautions:

      • General atrophy in target muscle.
      • Chronic respiratory disorder.
      • Elderly.
      • Excessive weakness in target muscle.
      • History of aspiration.
      • Dysphagia.
      • Inflammation in target muscle.
      • Neurological disorders.
      • Neuromuscular disorders.
      • Risk of angle-closure glaucoma (when used for blepharospasm or hemifacial spasm).
      • Reduced blinking can lead to corneal exposure, persistent epithelial defect, and corneal ulceration (especially in those with VIIth nerve disorders).
      • Common/Very Common side effects: alopecia, asthenia, autonomic dysreflexia, bladder diverticulum, brow ptosis, constipation, dizziness, drowsiness, dry eye, dry mouth, dysphagia, ecchymosis, eye discomfort, eye disorders, eye inflammation, facial paresis, fall, fever, gait abnormal, haematuria, headaches, hot flush, increased risk of infection, influenza-like illness, insomnia, joint disorders, leukocyturia, malaise, muscle complaints, muscle weakness, musculoskeletal stiffness, nausea, edema, pain, sensation abnormal, skin reactions, subcutaneous nodule, urinary disorders, vision disorders, anxiety, coordination abnormal, depression, dysphonia, dyspnoea, facial paralysis, memory loss, oral paraesthesia, photosensitivity reaction, postural hypotension, speech impairment, taste altered, vertigo.
      • Frequency not known: abdominal pain, angioedema, angle-closure glaucoma, appetite decreased, arrhythmia, diarrhea, hearing impairment, hypersensitivity, myocardial infarction, myopathy, nerve disorders, neuroromuscular dysfunction, pneumonia, aspiration (potentially fatal), respiratory disorders, seizure, syncope, tinnitus, vomiting.

    • Pregnancy: Avoid unless essential due to toxicity in animal studies.

    • Breastfeeding: Low risk of systemic absorption but avoid unless essential.

    • Dosage: 5000-10000 units, adjusted according to response, divided between 2-4 most affected muscles. Diluted with sodium chloride 0.9%.

    • Note: Botulinum toxin preparations are not interchangeable and should be used with caution.

    Parkinson's Disease

    • Progressive neurodegenerative condition caused by death of dopaminergic cells in the substantia nigra in the brain.
    • Motor symptoms: hypokinesia, bradykinesia, rigidity, rest tremor, postural instability.
    • Non-motor symptoms: dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems, weight loss.
    • Patients with suspected Parkinson's disease should be referred to a specialist and reviewed every 6 to 12 months.
    • When diagnosis is confirmed, patients should inform the DVLA and their car insurer.
    • Treatment is focused on controlling symptoms and improving quality of life.

    Parkinson's Disease Treatment

    • Non-drug Treatment:
      • Physiotherapy: Balance or motor function problems.
      • Speech and Language Therapy: Communication, swallowing or saliva problems.
      • Occupational Therapy: Difficulties with daily activities.
      • Dietitian Referral: Consider for nutritional needs.
    • Drug Treatment:
      • Early Stages: Levodopa combined with carbidopa or benserazide.
      • Motor symptoms not impacting quality of life: Levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole, rotigotine), or monoamine-oxidase-B inhibitors (rasagiline, selegiline hydrochloride).
      • Dyskinesia or Motor Fluctuations despite optimal levodopa therapy: Non-ergotic dopamine-receptor agonists, monoamine oxidase B inhibitors, or COMT inhibitors as an adjunct to levodopa.
    • Other Side Effects: daytime sleepiness, sudden onset of sleep, nocturnal akinesia, postural hypotension, depression, psychotic symptoms, rapid eye movement sleep behavior disorder, drooling of saliva, Parkinson's disease dementia, and impulse control disorders.
    • Drug Adjustment: Adjusted under specialist medical guidance.
    • Excessive Daytime Sleepiness: Modafinil should be considered.
    • Nocturnal Akinesia:
      • First-line : Levodopa or oral dopamine-receptor agonists.
      • If both are ineffective: Rotigotine.
      • If both are ineffective: Midodrine hydrochloride (first option), fludrocortisone acetate (alternative).
    • Driving: Patients should not drive, inform the DVLA about their symptoms, and consider any occupational hazards.
    • Monitoring: Treatment should be reviewed at least every 12 months.

    Promazine Hydrochloride

    • Used for treating cortical myoclonus, a condition characterized by dystonias and other involuntary movements.
    • Dosage: 7.2 g daily in 2-3 divided doses, then increased by 4.8 g every 3-4 days, adjusted according to response.
    • Contraindications: Cerebral hemorrhage, Huntington's chorea, gastric ulcer, history of hemorrhagic stroke, increased risk of bleeding, major surgery, underlying disorders of haemostasis.
    • Side effects: anxiety, movement disorders, weight increased, asthma, depression, drowsiness, angioedema, confusion, diarrhea, epilepsy exacerbated, gastrointestinal discomfort, hemorrhagic disorder, hallucination, headache, insomnia, nausea, skin reactions, vertigo, vomiting.
    • Hepatic Impairment: Manufacturers advise caution.
    • Renal Impairment: Manufacturers advise caution.

    Piracetam

    • Used as adjunctive treatment for cortical myoclonus.
    • For children 16 years and over.

    Pimozide

    • Used to treat Tourette syndrome and related choreas.

    Clonidine Hydrochloride

    • Used to treat Tourette syndrome and related choreas.

    Sulpiride

    • Used to treat Tourette syndrome and related choreas.

    Haloperidol

    • Used to suppress chorea in Huntington's disease.

    Olanzapine

    • Used to suppress chorea in Huntington's disease.

    Risperidone

    • Used to suppress chorea in Huntington's disease.

    Quetiapine

    • Used to suppress chorea in Huntington's disease.

    Trihexyphenidyl Hydrochloride

    • Can improve some movement disorders.
    • May be necessary to build up the dose over many weeks.

    Chlorpromazine Hydrochloride

    • Used to relieve intractable hiccups.

    Haloperidol

    • Used to relieve intractable hiccups.

    Propranolol Hydrochloride

    • Can be useful in treating essential tremor or tremors associated with anxiety or thyrotoxicosis.

    Primidone

    • Provides relief from benign essential tremor.

    Piracetam

    • Used as an adjunctive treatment for myoclonus of cortical origin.

    Riluzole

    • Used to extend life in patients with motor neurone disease who have amyotrophic lateral sclerosis.

    Botulinum Toxin Type A

    • Used for the treatment of torsion dystonia and other involuntary movements after an acquired non-progressive brain injury if rapid-onset spasticity causes postural or functional difficulties.

    Other drugs used for dystonias and other involuntary movements:

    • Clozapine
    • Diazepam
    • Orphenadrine hydrochloride
    • Pericyazine
    • Ramipexole
    • Prochlorperazine
    • Procyclidine hydrochloride
    • Ropinirole
    • Rotigotine
    • Trifluoperazine

    Parkinson's Disease Management

    • Depression should be treated with medications only if well tolerated.
    • Antiparkinsonism drugs should be reduced based on symptom severity and potential withdrawal effects.
    • Quetiapine can be used to treat hallucinations and delusions in Parkinson's patients without cognitive impairment.
    • Clozapine should be offered if standard treatments fail.
    • Rapid eye movement sleep behavior disorder should be treated with chloronazepam or melatonin after addressing pharmacological causes.
    • Drooling should be treated with non-drug therapies like speech and language therapy; drug treatment is only considered if non-drug options are ineffective.
    • Advanced Parkinson's Disease can be treated with intermittent injections or continuous subcutaneous infusions.
    • Nausea and vomiting associated with apomorphine should be managed with domperidone, started two days before therapy and discontinued as soon as possible.
    • Deep brain stimulation should be considered for patients with advanced Parkinson's disease whose symptoms are not adequately controlled by medication.
    • Impulse control disorders (ICDs) like compulsive gambling, hypersexuality, binge eating, or obsessive shopping can develop in Parkinson's patients on dopaminergic therapy.
    • Patients should be informed about ICDs and that dopamine-receptor agonist therapy can be reduced or stopped if ICDs develop.
    • Dopamine agonist doses should be gradually reduced and monitored for withdrawal symptoms.

    Procyclidine

    • Procyclidine treats Parkinson's disease by reducing central cholinergic excess caused by dopamine deficiency.
    • Adults are prescribed divided doses, with a maximum of 400mg per day.
    • Contraindications: acute porphyrias, gastrointestinal obstruction, cardiovascular disease, hypertension, angle-closure glaucoma.
    • Side effects: accommodation disorder, anxiety, dizziness, dry mouth, gastrointestinal disorders, nausea, confusion, constipation, coordination abnormality, euphoria, hallucinations, insomnia, sedation, seizures, tachycardia, urinary retention, Parkinson's disease, nervous system disorders (rare or very rare memory loss).
    • Advice: Pregnancy and breastfeeding are advised against. Liver impairment requires caution. Abrupt cessation of long-term treatment should be avoided.

    Trihexyphenidyl

    • Trihexyphenidyl reduces central cholinergic excess caused by dopamine deficiency.
    • It is recommended for Parkinson's disease, and in combination with levodopa.
    • Adults should maintain 2-6mg daily in divided doses, but it is not recommended for elderly patients due to toxicity and the risk of aggravating dementia.
    • Contraindications: myasthenia gravis, cardiovascular disease, elderly, gastrointestinal obstruction, hypertension, prostatic hypertrophy, psychotic disorders, pyrexia, angle-closure glaucoma.
    • Side effects: anxiety, confusion, constipation, delusions, dizziness, dry mouth, dysphagia, euphoria, fever, flushing, hallucinations, insomnia, memory loss, aggravated myasthenia gravis, mydriasis, nausea, skin reactions, tachycardia, thirst, urinary disorders, vision disorders, vomiting.
    • Advice: Pregnancy use is advised only if potential benefits outweigh risks. Breastfeeding should be avoided. Hepatic and renal impairment require caution. Abrupt cessation of long-term treatment should be avoided.

    Entacapone

    • Entacapone prevents peripheral breakdown of levodopa by inhibiting catechol-O-methyltransferase.
    • It is an adjunct to levodopa/dopa-decarboxylase inhibitor therapy in Parkinson's disease with 'end-of-dose' motor fluctuations.
    • Adults should take 200mg with each dose of levodopa, with a maximum of 2g per day.
    • Contraindications: history of neuroleptic malignant syndrome, non-traumatic rhabdomyolysis, phaeochromocytoma, concurrent levodopa dose needing reduction by about 10-30%, ischemic heart disease.
    • Side effects: abdominal pain, confusion, constipation, diarrhea, dizziness, dry mouth, falls, fatigue, hallucinations, hyperhidrosis, ischemic heart disease, movement disorders, nausea, sleep disorders, urine discoloration, vomiting, uncommon myocardial infarction, rare or very rare agitation, decreased appetite, skin reactions, weight loss, colitis, drowsiness, hair color changes, hepatic disorders, impulse control disorder, nail discoloration, neuroleptic malignant syndrome, and rhabdomyolysis.
    • Advice: Patient and caregiver advice is advised, as there may be reddish-brown urine and interactions with iron-containing products.

    Opicapone

    • Opicapone prevents the peripheral breakdown of levodopa by inhibiting catechol-O-methyltransferase.
    • It is recommended for Parkinson's disease patients with end-of-dose motor fluctuations, and should be taken at bedtime, at least one hour before or after levodopa combinations.
    • Contraindications: catecholamine-secreting neoplasms, history of neuroleptic malignant syndrome, non-traumatic rhabdomyolysis, paraganglioma, phaeochromocytoma.
    • It is contraindicated in patients experiencing progressive anorexia, asthenia, and weight decrease.
    • Advice: Liver function tests should be considered in patients experiencing progressive anorexia, asthenia, and weight decrease within a relatively short period of time. Pregnancy and breastfeeding should be avoided. Hepatic impairment requires caution.

    Tolcapone

    • Tolcapone treats Parkinson's disease and end-of-dose motor fluctuations in adults..
    • It is recommended to take 100mg three times a day, continuing beyond 3 weeks only after substantial improvement.
    • Side effects: common or very common constipation, dizziness, drowsiness, dry mouth, hallucinations, headache, hyperhidrosis, influenza-like illness, movement disorders, nausea, postural hypotension, sleep disorders, syncope, upper respiratory tract infection, urine discoloration, vomiting, hepatocellular injury, rare or very rare eating disorders, neuroleptic malignant syndrome, pathological gambling, psychiatric disorders, sexual dysfunction.
    • Advice: Patients should be informed about tolcapone's potential side effects, including phaeochromocytoma, previous history of hyperthermia, neuroleptic malignant syndrome, rhabdomyolysis, and severe dyskinesia. Most patients receiving more than 600mg levodopa daily require a reduction of levodopa dose by about 30%. Hepatotoxicity is a potential risk. Liver function should be tested before treatment and monitored regularly. Abrupt cessation of treatment should be avoided. Patients should be informed about the drug's interactions with other medications.

    Levodopa

    • Levodopa is used to treat Parkinson's disease.
    • Dosages vary based on patient characteristics and whether they are taking immediate-release levodopa/dopadecarboxylase inhibitor therapy.
    • Side effects: anxiety, decreased appetite, arrhythmia, depression, diarrhea, hallucination, movement disorders, nausea, parkinsonism, postural hypotension, sleep disorders, altered taste, vomiting, rare or very rare leucopenia, aggression, compulsions, confusion, delusions, dopamine dysregulation syndrome, drowsiness, eating disorders, euphoria, flushing, gastrointestinal hemorrhage, hemolytic anemia, hyperhidrosis, oral disorders, pathological gambling, psychosis, sexual dysfunction, skin reactions, thrombocytopenia, tongue discoloration, tooth discoloration, urine discoloration.
    • Risks: Cushing's syndrome, diabetes mellitus, endocrine disorders, history of convulsions, myocardial infarction with residual arrhythmia, movement disorders, nervous system disorders, peptic ulcer, hyperthyroidism, osteomalacia, phaeochromocytoma, psychiatric illness, severe cardiovascular disease, severe pulmonary disease, and susceptibility to angle-closure glaucoma.
    • Pregnancy: Use with caution due to toxicity in animal studies.
    • Breastfeeding: May suppress lactation and should be avoided.
    • Advice: Hepatic and renal impairment require caution. False positive tests for urinary ketones have been reported. Abrupt cessation of treatment should be avoided due to the risk of neuroleptic malignant syndrome and rhabdomyolysis.

    Cobeneldopa

    • Cobeneldopa is a mixture of benserazide hydrochloride and levodopa.
    • When transferring patients from other levodopa/dopa-decarboxylase inhibitor preparations, the previous preparation should be discontinued 12 hours before (interval can be shorter).
    • When switching from modified-release levodopa to dispersible co-beneldopa, reduce the dose by approximately 30%.
    • Patients and their carers should be given advice on how to administer co-beneldopa preparations.
    • Advice: Patients and their carers should be informed about the risk of developing dopamine dysregulation syndrome and addiction-like symptoms. Excessive daytime sleepiness and sudden onset of sleep can occur with co-beneldopa. Patients starting treatment should be cautious when driving or operating machinery. Those who have experienced excessive sedation or sudden onset of sleep should refrain from driving or operating machines until these effects have stopped occurring. Management of excessive daytime sleepiness should focus on identifying the underlying cause, such as depression or concomitant medication, and patients should be counseled on improving sleep behavior.

    Cocareldopa

    • Cocareldopa is a mixture of carbidopa and levodopa.
    • When transferring patients from other levodopa/dopa-decarboxylase inhibitor preparations, the previous preparation should be discontinued at least 12 hours before.
    • Patients and their carers should be informed about the risk of developing dopamine dysregulation syndrome and addiction-like symptoms.
    • Excessive daytime sleepiness and sudden onset of sleep can occur with co-careldopa, and patients starting treatment should be warned of the risk and exercise caution when driving or operating machinery.
    • Management of excessive daytime sleepiness should focus on identifying an underlying cause, such as depression or concomitant medication, and patients should be counseled on improving sleep behavior.
    • The Scottish Medicines Consortium (SMC) recommends Co-careldopa (Duodopa®) for the treatment of advanced levodopa-responsive Parkinson's disease with severe motor fluctuations and hyper-/dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results.
    • The All Wales Medicines Strategy Group (AWMSG) also recommends Levodopa-carbidopa intestinal gel (Duodopa®) for the treatment of advanced levodopa-responsive Parkinson's disease with severe motor fluctuations and hyper-/dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results and patients are not eligible for deep brain stimulation.

    Parkinson's Disease Medications

    • Levodopa/carbidopa/entacapone combination is effective in controlling Parkinson's disease and end-of-dose motor fluctuations.
    • Duodopa® is recommended for advanced Parkinson's disease with severe motor fluctuations and hyper-/dyskinesia when other combinations are ineffective.
    • Stalevo® is used for patients receiving standard-release co-careldopa or co-beneldopa alone, with dyskinesia, or receiving more than 800mg levodopa daily.
    • Amantadine hydrochloride is used to treat refractory motor fluctuations in Parkinson's disease and is prescribed under expert supervision.
    • Apomorphine is a stimulant of dopamine receptors in the brain, used to prevent lactation, suppress lactation, hypogonadism, galactoea, infertility, acromegaly, prolactinoma, and Parkinson's disease.
    • Bromocriptine is associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions. It should be prescribed carefully in patients with cardiovascular disease, history of peptic ulcer, history of serious mental disorders, and Raynaud's syndrome.
    • Cabergoline is a stimulant of dopamine receptors in the brain, used to treat Parkinson's disease and chronic endocrine disorders. Patients should be monitored for cardiac fibrosis by echocardiography.
    • Pramipexole is available in various dosages and is used to treat Parkinson's disease, cobeneldopa, and co-careldopa.
    • Ropinirole is a dopamine-receptor agonist used for Parkinson's disease and restless legs syndrome. Care should be taken to avoid confusion with risperidone.

    Dopamine-Receptor Agonists

    • Dopamine-receptor agonists are associated with impulse control disorders, including pathological gambling, binge eating, and hypersexuality.
    • Patients and their carers should be informed about the risk of impulse control disorders and the potential side effects of switching between dopamine-receptor agonists.
    • Patients starting treatment with dopamine-receptor agonists should be warned of the risk of excessive daytime sleepiness and sudden onset of sleep.
    • Hypotensive reactions can occur with dopamine-receptor agonists, especially during the first few days of treatment.
    • Treatment discontinuation should never be abrupt due to the small risk of neuroleptic malignant syndrome.
    • Prescribers and healthcare professionals should advise patients if treatment is likely to affect their ability to perform skilled tasks, especially when taking drugs with sedative effects.

    Important Considerations

    • Driving and Operating Machinery: Patients should be warned of the risk and exercise caution when driving or operating machinery while taking these medications.
    • Sleep Disruption: Excessive sedation and sudden onset of sleep should be reported and patients should refrain from driving or operating machines until these effects have passed.
    • Management of Sleepiness: Excessive daytime sleepiness should be investigated for underlying causes, such as depression or concomitant medication, and patients should be counseled on improving sleep behavior.
    • Dosage Adjustments: Dose adjustments may be necessary due to the risk of increased plasma concentration.
    • Monitoring Requirements: Specialists should monitor patients for pituitary enlargement, fibrotic disease, and blood pressure.
    • Blood Pressure Monitoring: Patients should be monitored for hypotension, particularly during the first few days of treatment.
    • Pregnancy and Breastfeeding: These medications are contraindicated in pregnancy and breastfeeding.
    • Hepatic and Renal impairment: Special care should be taken when prescribing these medications in patients with hepatic or renal impairment.

    Dopamine Receptor Agonists

    • Patient Counseling: Patients starting treatment with dopamine receptor agonists such as ropinirole should be informed of the risk of hypotensive reactions, particularly during the initial days of treatment. Counsel patients on improving sleep behaviors to manage potential excessive daytime sleepiness, and ensure they understand the importance of identifying causes of sleepiness.

    • Driving and Machinery: Patients should exercise caution when driving or operating machinery due to the risk of hypotensive reactions.

    • Drug Forms: Ropinirole is available in various forms, including tablets, modified-release tablets, and oral solutions. Several manufacturers offer special-order formulations.

    • National Funding: The Scottish Medicines Consortium (SMC) has approved Ropinirole tablets and Requip XL for the treatment of idiopathic Parkinson's disease with limitations.

    • Key Uses: Ropinirole is approved for treating moderate to severe idiopathic restless legs syndrome and idiopathic Parkinson's Disease.

    Rotigotine (Neupro)

    • Route of Administration: It is a transdermal patch available in doses ranging from 2mg to 8mg per 24 hours.

    • Indications: Used for treating Parkinson's disease and restless legs syndrome.

    • Adjunctive Therapy: Recommend adjunctive therapy with co-beneldopa or co-careldopa for Parkinson's disease.

    • Side Effects: A wide range of side effects is associated with Rotigotine, including:

      • Asthma
      • Behavioral abnormalities
      • Constipation
      • Dizziness
      • Drowsiness
      • Dry mouth
      • Dyskinesia
      • Eating disorders
      • Falls
      • Gastrointestinal discomfort
      • Hallucinations
      • Headaches
      • Hiccups
      • Hyperhidrosis
      • Hypertension
      • Hypotension
      • Loss of consciousness
      • Malaise
      • Nausea
      • Palpitations
      • Pathological gambling
      • Altered perception
      • Peripheral edema
      • Psychiatric disorders
      • Skin reactions
      • Sleep disorders
      • Syncope
      • Vertigo
      • Vomiting
      • Weight changes

    Rasagiline (Non-proprietary)

    • Mechanism: It is a monoamine oxidase B inhibitor.

    • Side Effects: The most common unwanted effects include:

      • Abdominal pain
      • Angina pectoris
      • Arthralgia
      • Arthritis
      • Conjunctivitis
      • Depression
      • Dermatitis
      • Dry mouth
      • Falls
      • Fever
      • Flatulence
      • Hallucinations
      • Headache
      • Increased risk of infection
      • Leucopenia
      • Malaise
      • Nausea
      • Neoplasms
      • Pain
      • Postural hypotension
      • Sleep disorders
      • Urinary urgency
      • Vertigo
      • Vomiting
      • Weight decreased
      • Decreased appetite
      • Confusion
      • Drowsiness
      • Eating disorders
      • Pathological gambling
      • Psychiatric disorders
      • Sexual dysfunction

    • Contraindications: Use with caution in patients with pre-existing dyskinesia. Avoid use in patients with:

      • Active retinopathy
      • Albinism
      • Family history of hereditary retinal disease
      • Retinal degeneration
      • Uveitis
      • Hypertension

    Safinamide (Zambon UK Ltd)

    • Mechanism: It is a monoamine oxidase B inhibitor.

    • Side Effects: The most common unwanted effects include:

      • Cataract
      • Dizziness
      • Drowsiness
      • Headache
      • Hypotension
      • Injury
      • Nausea
      • Sleep disorders
      • Abnormal anemia
      • Anxiety
      • Abnormal appetite
      • Arrhythmias
      • Asthenia
      • Cognitive disorder
      • Confusion
      • Constipation
      • Cough
      • Decreased leucocytes
      • Depression
      • Diarrhea
      • Dry mouth
      • Dysarthria
      • Dyslipidemia
      • Dyspnoea
      • Emotional lability
      • Eye disorders
      • Eye inflammation
      • Gastrointestinal discomfort
      • Glaucoma
      • Hallucinations
      • Hyperglycemia
      • Hypertension
      • Increased risk of infection
      • Joint disorders
      • Movement disorders
      • Muscle complaints
      • Muscle weakness
      • Neoplasms
      • Oral disorders
      • Pain
      • Palpitations
      • Peripheral edema
      • Photosensitivity reaction
      • Psychotic disorder
      • QT interval prolongation
      • Red blood cell abnormality
      • Rhinorrhoea
      • Abnormal sensation
      • Sensation of pressure
      • Sexual dysfunction
      • Skin reactions
      • Sweat changes
      • Syncope
      • Altered temperature sensation
      • Urinary disorders
      • Varicose veins
      • Vertigo
      • Vision disorders
      • Vomiting
      • Weight changes
      • Alopecia
      • Arterial spasm
      • Atherosclerosis
      • Benign prostatic hyperplasia
      • Breast abnormalities
      • Bronchospasm
      • Cachexia
      • Impaired concentration
      • Delirium
      • Diabetic retinopathy
      • Dysphonia
      • Eosinophilia
      • Eye pain
      • Fat embolism
      • Fever
      • Gambling
      • Hemorrhage
      • Hyperbilirubinemia
      • Hyperkalemia
      • Illusion
      • Malaise
      • Myocardial infarction
      • Oropharyngeal complaints
      • Osteoarthritis
      • Paranoia
      • Psychiatric disorders
      • Pyuria
      • Decreased reflexes
      • Suicidal ideation
      • Altered taste

    • Pregnancy and Breastfeeding: Avoid Safinamide during pregnancy and breastfeeding due to the potential toxicity found in animal studies.

    Selegiline Hydrochloride

    • Mechanism: It's a monoamine oxidase B inhibitor.

    • Indications: Used to treat Parkinson's disease, either alone or as adjunctive therapy to co-beneldopa or co-careldopa for reducing disease deterioration.

    • Dosage: Immediate-release medications are recommended with a starting dose of 5mg once daily for 2 to 4 weeks, increasing to 10mg daily if tolerated. Oral lyophilisates are also available with a dose of 1.25mg taken before breakfast.

    • Contraindications: Avoid using selegiline in patients with:

      • Active duodenal ulceration and gastric ulceration
      • Angina
      • Arrhythmias
      • Duodenal ulceration
      • Gastric ulceration
      • History of hepatic dysfunction
      • Confusion
      • Psychosis
      • Uncontrolled hypertension

    • Side Effects: The most common side effects include:

      • Arrhythmias

      • Arthralgia

      • Back pain

      • Confusion

      • Constipation

      • Depression

      • Diarrhea

      • Dizziness

      • Dry mouth

      • Falls

      • Fatigue

      • Hallucinations

      • Headache

      • Hyperhidrosis

      • Hypertension

      • Hypotension

      • Movement disorders

      • Muscle cramps

      • Nasal congestion

      • Nausea

      • Oral disorders

      • Sleep disorders

      • Throat pain

      • Tremor

      • Vertigo

      • Uncommonly reported effects include:

        • Alopecia
        • Angina pectoris
        • Anxiety
        • Decreased appetite
        • Chest pain
        • Dyspnea
        • Leucopenia
        • Altered mood
        • Myopathy
        • Palpitations
        • Peripheral edema
        • Pharyngitis
        • Psychosis
        • Skin eruption
        • Thrombocytopenia
        • Urinary disorders
        • Blurred vision

      • Rare or Very Rare side effects:

        • Alopecia
        • Arterial spasm
        • Atherosclerosis
        • Benign prostatic hyperplasia
        • Breast abnormalities
        • Bronchospasm
        • Cachexia
        • Impaired concentration
        • Delirium
        • Diabetic retinopathy
        • Dysphonia
        • Eosinophilia
        • Eye pain
        • Fat embolism
        • Fever
        • Gambling
        • Hemorrhage
        • Hyperbilirubinemia
        • Hyperkalemia
        • Illusion
        • Malaise
        • Myocardial infarction
        • Oropharyngeal complaints
        • Osteoarthritis
        • Paranoia
        • Psychiatric disorders
        • Pyuria
        • Decreased reflexes
        • Suicidal ideation
        • Altered taste

      • Manufacturer Advice: Avoid abrupt withdrawal of selegiline. Exercise caution in patients with mild hepatic impairment.

    • Patient Advice: Counsel on how to properly administer selegiline oral lyophilisates. Advise on the potential impact of treatment on performing skilled tasks.

    Levodopa

    • Side Effects: Patients taking concurrent levodopa should have their dosage gradually reduced in steps of 10% every 3 to 4 days to manage potential side effects.

    • Contraindications: Avoid levodopa in patients:

      • During pregnancy and breastfeeding
      • With hepatic impairment
      • With renal impairment
      • With a history of stopping treatment

    Antiemetics

    • General Principles: Prescribe antiemetics only when the cause of nausea and vomiting is known.

    • Drug Classes:

      • Antihistamines:

        • Cinnarizine
        • Cyclizine
        • Promethazine hydrochloride
        • Promethazine teoclate

      • Phenothiazines:

        • Chlorpromazine hydrochloride
        • Prochlorperazine
        • Trifluoperazine

      • Metoclopramide Hydrochloride: Resembles phenothiazines and may be superior for emesis associated with gastrointestinal and biliary disease.

      • Domperidone: Works at the chemoreceptor trigger zone and does not readily cross the blood-brain barrier.

      • 5HT3-Receptor Antagonists:

        • Granisetron
        • Ondansetron
        • Palonosetron

      • Dexamethasone: Antiemetic effects and used in chemotherapy-induced nausea and vomiting.

      • Neurokinin 1-Receptor Antagonists:

        • Aprepitant
        • Fosaprepitant

      • Nabilone: Synthetic cannabinoid with antiemetic properties.

    Nausea and Vomiting: Specific Conditions

    • Pregnancy:

      • Nausea and vomiting are common during pregnancy.
      • Symptoms often resolve within 16 to 20 weeks.
      • Offer self-care advice, such as rest, hydration, and dietary modifications.
      • Inform about available support options.
      • Consider antiemetics for persistent symptoms if self-care is ineffective.
      • Ginger may provide relief for mild to moderate nausea.
      • Antiemetic options include chlorpromazine hydrochloride, cyclizine, doxylamine with pyridoxine, metoclopramide hydrochloride, prochlorperazine, promethazine hydrochloride, promethazine teoclate, and ondansetron.

    • Postoperative:

      • The incidence of postoperative nausea and vomiting (PONV) depends on various factors, including type of surgery, anesthetic used, and patient history.
      • Prevention and treatment should be based on individualized risk factors.
      • Combinations of antiemetics with different mechanisms of action are often recommended.
      • Medications used include 5HT3-receptor antagonists, dexamethasone, droperidol, and haloperidol.
      • Cyclizine and prochlorperazine are licensed for PONV caused by opioids and general anesthetics.

    • Motion Sickness:

      • Antihistamines can effectively prevent symptoms like nausea, vomiting, and vertigo.
      • Hyoscine hydrobromide is licensed specifically for motion sickness.
      • Cinnarizine and cyclizine may also be helpful.
      • Domperidone, metoclopramide hydrochloride, 5HT3-receptor antagonists, and phenothiazines are ineffective.

    • Ménière's Disease:

      • Refer patients with symptoms to an ear, nose, and throat specialist for diagnosis.
      • Antihistamines and phenothiazines relieve nausea, vomiting, and vertigo during acute attacks.
      • Buccal prochlorperazine or deep intramuscular injections of prochlorperazine or cyclizine can rapidly manage severe acute attacks.
      • Betahistine dihydrochloride can reduce the frequency and severity of hearing loss, tinnitus, and vertigo in recurrent attacks.

    • Migraines:

      • Antiemetics and anti-inflammatories are used to treat migraines.

    Cyclizine

    • Mechanism: It is a first-generation antihistamine that selectively binds to H1 receptors in the brain.

    • Indications: A wide range of conditions, including:

      • Agitation
      • Angle closure glaucoma
      • Depression
      • Abdominal pain
      • Angioedema
      • Anxiety
      • Apnea
      • Decreased appetite
      • Arrhythmias
      • Asthenia
      • Bronchospasm
      • Constipation
      • Diarrhea
      • Disorientation
      • Dizziness
      • Drowsiness
      • Dry mouth
      • Dry throat
      • Euphoria
      • Hemolytic anemia
      • Hallucinations
      • Headache
      • Hepatic disorders
      • Hypertension
      • Hypotension
      • Increased gastric reflux
      • Insomnia
      • Leucopenia
      • Movement disorders
      • Muscle complaints
      • Nasal dryness
      • Nausea
      • Oculogyric crisis
      • Palpitations
      • Paraesthesia
      • Photosensitivity reaction
      • Seizures
      • Skin reactions
      • Speech disorder
      • Thrombocytopenia
      • Tinnitus
      • Tremor
      • Urinary retention
      • Blurred vision
      • Vomiting

    • Side Effects:

      • With oral use: decreased level of consciousness
      • With parenteral use: chills, impaired consciousness, injection site necrosis, pain, paralysis, sensation of pressure, thrombophlebitis

    • Manufacturer Advice: Avoid using sedating antihistamines during the latter part of the third trimester due to potential adverse effects in neonates.

    • Breastfeeding: Most antihistamines are present in breast milk, and their use in breastfeeding mothers is generally advised against.

    • Administration: Tablets can be crushed for oral administration.

    • Palliative Care: Syringe drivers in palliative care should be closely monitored. Cyclizine may precipitate at concentrations above 10 mg/mL. Mixing diamorphine and cyclizine increases the risk of precipitation after 24 hours.

    • Patient Advice: Inform patients about the risk of drowsiness and its impact on skilled tasks.

      • Alcohol may enhance the effects of cyclizine.
      • Different medicines containing the same drug can be licensed differently.

    Doxylamine with Pyridoxine (Xonvea)

    • Indications: Used for treating nausea and vomiting during pregnancy, specifically caused by cytotoxic chemotherapy.

    • Dosage: Start with 20/20mg once daily for 2 days, taken at bedtime. The dosage may be increased if necessary.

    • Side Effects:

      • Dizziness
      • Drowsiness
      • Dry mouth
      • Fatigue

    • Driving and Skilled Tasks: Avoid driving and performing skilled tasks due to the risk of somnolence and dizziness.

    • National Funding: The Scottish Medicines Consortium (SMC) and All Wales Medicines Strategy Group (AWMSG) do not recommend this medication for women who do not respond to conservative management.

    Xonvea

    • Xonvea is available in gastro-resistant tablets, with a dosage of 10mg/10mg.
    • The manufacturer advises patients and caregivers to be counseled on the effects of Xonvea on driving and performing skilled tasks due to the increased risk of somnolence and dizziness.

    Nabilone

    • Nabilone can cause nausea and vomiting in pregnancy.
    • It is not recommended for use in a hospital setting.
    • Nabilone should be taken at least two times daily throughout each cycle of cytotoxic chemotherapy, with the first dose taken the night before initiation of treatment and the second dose 1–3 hours before the first dose.
    • Adverse effects on the mental state can persist for 48–72 hours after stopping Nabilone.
    • Drowsiness and dizziness occur frequently with standard doses of Nabilone.
    • Pregnancy should be avoided unless essential, and breastfeeding should be avoided while taking Nabilone.
    • The manufacturer advises against using Nabilone in severe impairment, particularly biliary excretion.
    • Patients and their caregivers should be aware of potential changes in mood and other adverse behavioral effects, such as drowsiness that may affect the performance of skilled tasks.
    • Alcohol can also enhance the effects of nabilone, which is a controlled drug.

    Domperidone

    • Domperidone is used for the relief of nausea and vomiting in children aged 12-17 years or those weighing less than 35 kg.
    • A European review concluded that domperidone is not as effective in this population as previously thought.
    • Alternative treatments should be considered for nausea and vomiting in children.
    • Healthcare professionals are advised to adhere to the licensed dose and use the lowest effective dose for the shortest possible duration.
    • Domperidone has several side-effects, including dry mouth, anxiety, asthenia, breast abnormalities, diarrhea, drowsiness, headache, lactation disorders, libido loss, arrhythmias, depression, gynaecomastia, menstrual cycle irregularities, movement disorders, oculogyric crisis, QT interval prolongation, seizure, sudden cardiac death, and urinary retention.
    • Palliative care uses domperidone only if potential benefit outweighs risk.
    • Breastfeeding amounts are too small to be harmful, and the manufacturer advises avoiding domperidone in moderate to severe impairment.
    • Renal impairment can lead to dose adjustments, and for repeated doses, consider dose reduction and reduce frequency of administration.
    • Patients and their carers should be told how to recognize signs of arrhythmia and seek medical attention if symptoms such as palpitation or syncope develop.
    • Medicine forms available from special-order manufacturers include oral suspension, tablets, and nabilone (Zentiva Pharma UK Ltd).

    Dopamine receptor antagonists

    • Dopamine receptor antagonists like nabilone can cause side effects, such as dry mouth, anxiety, asthenia, breast abnormalities, diarrhea, drowsiness, headache, lactation disorders, libido loss, arrhythmias, depression, gynaecomastia, menstrual cycle irregularities, movement disorders, oculogyric crisis, QT interval prolongation, seizure, sudden cardiac death, and urinary retention.
    • In summary, patients and caregivers should be aware of potential changes in mood and adverse behavioral effects of domperidone, including drowsiness, gastrointestinal issues, and increased risk of ventricular arrhythmia.

    Metoclopramide

    • Metoclopramide is a medication used for the treatment of nausea and vomiting, including those associated with acute migraines.
    • It is prescribed for adults over 18 years old for prevention of postoperative nausea and vomiting, radiotherapy-induced nausea and vomiting, delayed chemotherapy-induced nausea and vomiting, and symptomatic treatment of nausea and vomiting, including that associated with acute migraines.
    • The European Medicines Agency's Committee on Medicinal Products for Human Use has reviewed the benefits and risks of metoclopramide, concluding that the risk of neurological effects such as extrapyramidal disorders and tardive dyskinesia outweighs the benefits in long-term or high-dose treatment.
    • To minimize the risk of potentially serious neurological adverse effects, restrictions have been made to the indications, dose, and duration of use.
    • In adults over 18 years old, the usual dose is 10 mg, repeated up to three times daily; the max. daily dose is 500 micrograms/kg.
    • Intravenous doses should be administered as a slow bolus over at least 3 minutes, and oral liquid formulations should be given via an appropriately designed, graduated oral syringe to ensure dose accuracy.
    • This advice does not apply to unlicensed uses of metoclopramide (e.g., palliative care).
    • Contra-indications include epilepsy, gastro-intestinal haemorrhage, gastrointestinal obstruction, gastro-intestinal perforation, and phaeochromocytoma.
    • Cautions include asthma, atopic allergy, bradycardia, cardiac conduction disturbances, children, elderly, and patients with parkinsonism.
    • Elderly prescriptions may be potentially inappropriate (STOPP criteria) in patients with parkinsonism.
    • General side-effects include asthma, depression, diarrhea, drowsiness, hypotension, menstrual cycle irregularities, movement disorders, parkinsonism, uncommon arrhythmias, hallucinations, hyperprolactinemia, decreased level of consciousness, confusion, galactorrhoea, seizure, and frequency not known Atrioventricular block, blood disorders, cardiac arrest, gynaecomastia, hypertension, neuroleptic malignant syndrome, QT interval prolongation, shock, syncope, tremor.
    • Specific side-effects include anxiety, dizziness, dyspnoea, oedema, skin reactions, and visual impairment.
    • Metoclopramide is a medication that can induce acute dystonic reactions, including facial and skeletal muscle spasms and oculogyric crises.
    • These effects are more common in the young and very old and usually occur shortly after starting treatment with metoclopramide and subside within 24 hours of stopping it.
    • Injection of an antiparkinsonian drug such as procyclidine will abort dystonic attacks.
    • Pregnancy is not known to be harmful, and there is a small amount present in milk; avoid.
    • The manufacturer advises caution in severe impairment (risk of accumulation) and dose adjustments in hepatic impairment.
    • Dose adjustments include reducing daily dose by 75% in endstage renal disease and 50% in moderate to severe impairment.
    • Palliative care for metoclopramide hydrochloride can be provided through a graduated oral dosing syringe.
    • There can be variation in the licensing of different medicines containing the same drug, with forms available from special-order manufacturers such as oral solution, injection solution, tablet, and maxolon tablets.

    Neurokinin receptor antagonists

    • Neurokinin receptor antagonists are used to prevent nausea and vomiting associated with moderately and highly emetogenic chemotherapy.
    • Adults should take 125 mg of metoclopramide hydrochloride one hour before chemotherapy, then 80 mg once daily for two days.
    • Contra-indications include acute porphyrias and interactions with neurokinin-1 receptor antagonists.
    • Side effects include common or very common appetite decreased, asthenia, constipation, gastrointestinal discomfort, headache, hiccups, anemia, anxiety, burping, dizziness, drowsiness, dry mouth, febrile neutropenia, gastrointestinal disorders, hot flush, malaise, nausea, palpitations, skin reactions, urinary disorders, vomiting, rare or very rare Bradycardia, cardiovascular disorder, chest discomfort, cognitive disorder, conjunctivitis, cough, disorientation, euphoric mood, gait abnormal, hyperhidrosis, increased risk of infection, muscle spasms, muscle weakness, oedema, oropharyngeal pain, photosensitivity reaction, polydipsia, seborrhoea, severe cutaneous adverse reactions (SCARs), sneezing, stomatitis, taste altered, throat irritation, tinnitus, weight decreased, and frequency not known.
    • Pregnancy is advised to avoid unless clearly necessary, and breastfeeding is advised due to its presence in milk in animal studies.

    Fosaprepitant

    • The drug fosaprepitant is a prodrug of aprepitant, used to prevent nausea and vomiting associated with moderately and highly emetogenic chemotherapy.
    • It is administered by intravenous infusion and is recommended for adults over 150 mg.
    • Side effects include decreased appetite, asthenia, constipation, gastrointestinal discomfort, headache, hiccups, anemia, anxiety, burping, dizziness, drowsiness, dry mouth, febrile neutropenia, flushing, gastrointestinal disorders, malaise, nausea, palpitations, skin reactions, thrombophlebitis, urinary disorders, vomiting, Bradycardia, cardiovascular disorder, chest discomfort, cognitive disorder, conjunctivitis, cough, disorientation, euphoric mood, gait abnormal, hyperhidrosis, increased risk of infection, muscle spasms, muscle weakness, oedema, oropharyngeal pain, photosensitivity reaction, polydipsia, seborrhoea, severe cutaneous adverse reactions (SCARs), sneezing, stomatitis, taste altered, throat irritation, tinnitus, weight decreased, frequency not known, dysarthria, dyspnoea, insomnia, miosis, sensation abnormal, visual acuity decreased, and wheezing.
    • The effectiveness of hormonal contraceptives is reduced, and effective nonhormonal methods of contraception are necessary during treatment and for 2 months after stopping fosaprepitant.
    • Pregnancy should be avoided unless potential benefit outweighs risk, and breastfeeding should be avoided due to its presence in milk in animal studies.
    • The manufacturer advises caution in moderate to severe impairment.
    • For intravenous infusion, the manufacturer advises giving intermittently in sodium chloride 0.9%, reconstitute each 150mg vial with 5 mL sodium chloride 0.9% gently without shaking to avoid foaming, then dilute in 145mL infusion fluid and give over 20-30 minutes.

    Granisetron

    • Granisetron is a specific 5HT3-receptor antagonist that blocks 5HT3 receptors in the gastrointestinal tract and in the CNS.
    • In summary, fosaprepitant is a medication used to prevent nausea and vomiting associated with highly emetogenic chemotherapy in adults.
    • It is recommended to consult product literature for doses and interactions with other medications.
    • The text provides information on the use of Granisetron, a medication used to treat nausea and vomiting induced by cytotoxic chemotherapy.
    • It is recommended for intravenous application using patches, with adult patients applying 3.1 mg/24 hours to clean, dry, non-irritated, non-hairy skin on their upper arm or abdomen 24–48 hours before treatment.
    • The patch may be worn for up to 7 days and removed at least 24 hours after completing chemotherapy.
    • Prevention of postoperative nausea and vomiting can be achieved through intravenous injection, with 1 mg administered before induction of anesthesia.
    • Treatment of postoperative nausea and vomiting can be achieved through intravenous injection, with a maximum combined total dose of 9 mg in 24 hours.
    • Interactions with Granisetron include subacute intestinal obstruction, susceptibility to QT-interval prolongation, and interactions with 5-HT3-receptor antagonists.
    • Side effects include general side effects such as constipation and headache, as well as specific side effects like diarrhea, insomnia, extrapyramidal symptoms, QT interval prolongation, serotonin syndrome, decreased appetite, arthralgia, dry mouth, flushing, generalized oedema, vertigo, and dystonia.
    • The manufacturer advises against pregnancy, breast feeding, and hepatetic impairment.
    • For intravenous infusion, the manufacturer advises giving intermittently in glucose 5% or sodium chloride 0.9%, diluting up to 3mL in 20–50mL infusion fluid over 5 minutes.
    • Patients should not expose the site of the patch to sunlight during use and for 10 days after removal.
    • Medicinal forms for Granisetron include Granisetron (non-proprietary) tablets, Kytril tablets, and Sancuso transdermal patches.

    Ondansetron

    • Ondansetron is available in various forms, including oral and transdermal patches.
    • Ondansetron is a specific 5HT3-receptor antagonist that blocks 5HT3 receptors in the gastrointestinal tract and the central nervous system.
    • It is used for moderately emetogenic chemotherapy or radiotherapy, with dosages ranging from 8 mg to 24 mg.
    • For elderly patients, the dose is 8 mg, followed by 8 mg every 12 hours for up to 5 days.
    • Elderly patients should be given 8 mg immediately before treatment, followed by intravenous infusion for at least 15 minutes.
    • Severely emetogenic chemotherapy can be administered by 24 mg, with dosages ranging from 8 mg to 16 mg daily for up to 5 days.
    • Elderly patients should be given 8 mg immediately before treatment, followed by 8 mg every 12 hours for up to 5 days.
    • Intranavenous infusion can be given 1 mg/hour for up to 24 hours, then 8 mg every 12 hours for up to 5 days, or 16 mg daily for up to 5 days.
    • Intravenous infusion can be given 1 mg/hour for up to 24 hours, then 8 mg every 12 hours for up to 5 days, or 16 mg daily for up to 5 days.
    • Adults 65-74 years and over should be given 8-16 mg immediately before treatment, followed by 8 mg every 4 hours if required for 2 doses.
    • Postoperative nausea and vomiting can be prevented by administering 4 mg for 1 dose.
    • The manufacturer advises against ondansetron use during the first 12 weeks of pregnancy due to a small increased risk of congenital long QT syndrome.
    • Contraindications include congenital long QT syndrome, contraindications include adenotonsillar surgery, subacute intestinal obstruction, and susceptibility to QT-interval prolongation.
    • Interactions with ondansetron include common side effects such as constipation, feeling hot, headache, sensation abnormal, arrhythmias, chest pain, hiccups, hypotension, movement disorders, oculogyric crisis, seizure, dizziness, QT interval prolongation, and vision disorders.
    • Pregnancy is advised to avoid ondansetron use due to the small increased risk of congenital abnormalities such as orofacial clefts.
    • Breathing in milk in animal studies should be avoided.
    • In moderate to severe impairment, caution is advised, with maximum 8mg daily doses recommended.

    Palonosetron

    • Palonosetron is a specific 5HT3-receptor antagonist that blocks 5HT3 receptors in the gastrointestinal tract and in the central nervous system.
    • It is used in moderately emetogenic chemotherapy, initially by mouth, with a dose of 500 micrograms taken 1 hour before treatment or 250 micrograms for one dose administered over 30 seconds, 30 minutes before treatment.
    • For severely emetogenic chemotherapy, by intravenous injection, with a dose of 250 micrograms for one dose, administered over 30 seconds, 30 minutes before treatment.
    • General side effects include constipation and headache, while specific side effects include diarrhea, dizziness, electrolyte imbalance, metabolic disorder, amblyopia, anxiety, appetite decreased, arrhythmias, arthralgia, asthenia, drowsiness, dry mouth, dyspepsia, euphoric mood, eye irritation, feeling hot, fever, flatulence, glycosuria, hiccups, hyperbilirubinaemia, hyperglycaemia, hypertension, hypotension, influenza-like illness, motion sickness, myocardial ischaemia, paraesthesia, peripheral neuropathy, QT interval prolongation, skin reactions, sleep disorders, tinnitus, urinary retention, vasodilation, vein discolouration, atrioventricular block, dyspnoea, eye swelling, insomnia, myalgia, rare or very rare, and shock.
    • Paloronosetron's oral formulations may include strawberry flavors.
    • Patients or carers should be given advice on how to administer orodispersible films and lyophilisates.
    • There can be variation in the licensing of different medicines containing the same drug, and forms available from special-order manufacturers include oral suspension, oral solution, orodispersible film, Setofilm, and oral lyophilisate.
    • Palonosetron's side effects include general side effects such as constipation and headache, and specific side effects such as diarrhea, dizziness, electrolyte imbalance, metabolic disorder, amblyopia, anxiety, appetite decreased, arrhythmias, arthralgia, asthenia, drowsiness, dry mouth, dyspepsia, euphoric mood, eye irritation, feeling hot, fever, flatulence, glycosuria, hiccups, hyperbilirubinaemia, hyperglycaemia, hypertension, hypotension, influenza-like illness, motion sickness, myocardial ischaemia, paraesthesia, peripheral neuropathy, QT interval prolongation, skin reactions, sleep disorders, tinnitus, urinary retention, vasodilation, vein discoloration, atrioventricular block, dyspnoea, eye swelling, insomnia, myalgia, and shock.
    • In summary, palonosetron is a medication used for moderately emetogenic chemotherapy, with various side effects and interactions.
    • Patients should consult their healthcare provider for proper administration and follow the recommended dosage and dosage for each treatment.

    Palonosetron with netupitant

    • The manufacturer of a medication called Palonosetron with netupitant (Akynzeo®) recommends its use in adults for the prevention of acute and delayed nausea and vomiting associated with highly emetogenic cisplatin-based cancer chemotherapy and moderately emetogenic cancer chemotherapy.
    • The medication is available in two forms: non-proprietary Palonosetron (50 microgram per 1 ml) and Aloxi (Chugai Pharma UK Ltd).
    • The combination of these medications has been shown to be effective in treating various conditions, including moderately emetogenic chemotherapy and highly emetogenic cancer chemotherapy.
    • The manufacturer advises against pregnancy before treatment in females of childbearing age, ensure effective contraception during treatment, and for one month after treatment.
    • Pregnancy is advised due to toxicity in animal studies.
    • Breastfeeding is advised to avoid during treatment and for one month after the last dose.
    • The manufacturer also advises caution in severe impairment due to the risk of increased exposure and limited information available.
    • The manufacturer also recommends the use of sedating antihistamines in the latter part of the third trimester, as there is no evidence of teratogenicity.
    • The use of sedating antihistamines in the latter part of the third trimester may cause adverse effects in neonates such as irritability, paradoxical excitability, and tremor.
    • In summary, the manufacturer of Palonosetron with netupitant recommends its use in adults for the prevention of acute and delayed nausea and vomiting associated with highly emetogenic cisplatin-based cancer chemotherapy and moderately emetogenic cancer chemotherapy.
    • However, there is no evidence of teratogenicity, and the use of sedating antihistamines in the latter part of the third trimester may cause adverse effects in neonates.
    • It is important to consult the manufacturer's guidelines and information on the potential side effects of these medications before taking them.

    Antihistamines

    • Most antihistamines are present in breast milk in varying amounts, and although not known to be harmful, most manufacturers advise avoiding their use in mothers who are breastfeeding.
    • Hepatic impairment is advised by the manufacturer, and renal impairment is used with caution.
    • Drowsiness may affect the performance of skilled tasks, such as cycling or driving, and sedating effects are enhanced by alcohol.
    • Medicinal forms for antihistamines can vary, with special-order manufacturers offering oral suspensions and tablets.
    • Vertigo is recommended for adults, while Cinnarizine and Dimenhydrinate are available in tablets.
    • Promethazine teoclate is also recommended for children aged 5-9 years.
    • Motion sickness prevention is advised for children aged 5-9 years, with doses taken at bedtime on night before travel or 1-2 hours before travel.
    • Treatment is advised for children aged 10-17 years, with doses taken at bedtime on night before travel or 1-2 hours before travel.
    • Children under 6 years should not be given over-the-counter cough and cold medicines containing promethazine.

    Antihistamines

    • Potential side effects include anticholinergic syndrome, anxiety, decreased appetite, arrhythmia, blood disorder, bronchial secretion, viscosity increased, confusion, dizziness, drowsiness, dry mouth, epigastric discomfort, fatigue, haemolytic anemia, headache, hypotension, jaundice, movement disorders, muscle spasms, nightmare, palpitations, photosensitivity reaction, urinary retention, and vision blurred.
    • Elderly patients are more susceptible to anticholinergic side-effects.
    • Paradoxical stimulation may occur in children with high doses.
    • Pregnancy is advised by most manufacturers, but there is no evidence of teratogenicity.
    • Use in the latter part of the third trimester may cause adverse effects in neonates such as irritability, paradoxical excitability, and tremor.
    • Antihistamines are present in breast milk in varying amounts, and their use should be avoided in cases of hepatic impairment, renal impairment, and other health conditions.

    Antimuscarinic Medications - Avomine and Vertigon

    • Avomine and Vertigon contain Promethazine teoclate 25 mg tablets.
    • They are used for antimuscarinics with various indications and doses, including for motion sickness in children aged 4-9 years, hypersalivation associated with clozapine therapy in adults, excessive respiratory secretion in palliative care, continuous subcutaneous injection, and bowel colic pain in palliative care.

    Hyoscine Hydrobromide

    • Premedication available for hyoscine hydrobromide, administered by subcutaneous injection or intramuscular injection 30-60 minutes before induction of anesthesia.
    • Not licensed for hypersalivation associated with clozapine therapy.
    • Antimuscarinic drugs used for premedication to general anesthesia should only be administered by personnel experienced in their use.
    • Potential side effects include eye disorders, eyelid irritation, concentration impaired, glaucoma, hallucinations, memory loss, restlessness, and seizures.
    • In some cases, it may cause the central anticholinergic syndrome in adults and in some children.
    • In pregnancy, use only if potential benefit outweighs risk, as injection may depress neonatal respiration.
    • Breast feeding is too small to be harmful, and the manufacturer advises caution for hyoscine.
    • For renal impairment, use with caution.

    Hyoscine Hydrobromide - Further Information

    • Medication used for antimuscarinics, with various indications and doses.
    • Should only be administered under the direct supervision of experienced personnel.
    • Used to treat postoperative nausea and vomiting.
    • Recommended for transdermal use in children, with patches applied to the hairless area of skin behind the ear.
    • For oral use in children, injection solution may be given orally.
    • Chewable tablet formulations may include raspberry flavors.
    • Palliative care information can be found at www.medicinescomplete.com/#/content/palliative/hyo.
    • Patient and caregiver advice emphasizes washing hands after handling and using one patch at a time.
    • Drowsiness may persist for up to 24 hours or longer after removal of the patch, with alcohol effects enhanced.
    • Medicinal forms available from special-order manufacturers include oral suspension and oral solution.
    • Tablets include Kwells (Dexcel-Pharma Ltd), Travel Calm (The Boots Company Plc), Hyoscine hydrobromide (Non-proprietary), Scopoderm (Baxter Healthcare Ltd), Joy-Rides (Teva UK Ltd), and Joy-Rides 150 microgram chewable tablets sugar-free.

    Droperidol

    • A butyrophenone structurally related to haloperidol, which blocks dopamine receptors in the chemoreceptor trigger zone.
    • Preventing and treating postoperative nausea and vomiting involves intravenous injection of 0.625–1.25 mg for adults and 625 micrograms for the elderly.
    • In postoperative patient-controlled analgesia (PCA), 15–50 micrograms of droperidol are recommended for every 1 mg of morphine, with a maximum dose of 5 mg per day.
    • Contra-indications include bradycardia, comatose states, hypokalemia, hypomagnesaemia, phaeochromocytoma, QT-interval prolongation, and contraindications include chronic obstructive pulmonary disease, CNS depression, electrolyte disturbances, history of alcohol abuse, and respiratory failure.
    • Interactions with droperidol include anxiety, oculogyration, rare or very rare blood disorders, cardiac arrest, dysphoria, coma, epilepsy, hallucination, oligomenorrhoea, respiratory disorders, SIADH, and syncope.
    • HEPATIC IMPAIRMENT manufacturers advise caution and dosing adjustments when used for prevention and treatment of postoperative nausea and vomiting.
    • Renal impairment requires continuous pulse oximetry for monitoring.
    • Hyoscine hydrobromide is a medication used for pain management and palliative care.
    • It is recommended to follow instructions and follow proper dosage and monitoring for side effects.

    Levomepromazine

    • Medication used in palliative care for patients with severe pain unresponsive to other measures.
    • Prescribed for pain in palliative care, restlessness and confusion, nausea and vomiting, and schizophrenic (bed patients) in adults.
    • Dosage is 6 mg every 2 hours as required, with doses increasing if necessary.
    • For intravenous injection, the dosage is 6 mg every 2 hours, with doses increasing if necessary.
    • In children aged 1-11 years, the dosage is 100-400 micrograms/kg, administered over 24 hours.
    • For children aged 12-17 years, the dosage is 5-25 mg, administered over 24 hours.
    • Dosage can be increased if necessary.
    • Schizophrenic patients should take 25-50 mg daily in divided doses, with the dose increasing as needed.
    • Contra-indications include CNS depression, comatose states, and phaeochromocytoma.
    • Patients receiving large initial doses should remain supine.
    • In adults, there is a risk of postural hypotension, and it is not recommended for ambulant patients over 50 years unless the risk of hypotensive reaction is assessed.
    • Side effects include asthma, heat stroke, cardiac arrest, hepatic disorders, allergic dermatitis, delirium, gastrointestinal disorders, glucose tolerance impaired, photosensitivity reaction, priapism, and SIADH.
    • The manufacturer advises considering avoiding this medication.
    • For subcutaneous use in children, the manufacturer advises diluting with a suitable volume of sodium chloride 0.9%.
    • For injection, the manufacturer recommends Levomepromazine hydrochloride 25 mg per 1 ml and Nozinan (Sanofi) 25 mg per 1 ml.

    Betahistine Dihydrochloride

    • Ménière's disease is associated with vertigo, tinnitus, and hearing loss.
    • Adults should take 16 mg three times a day, preferably with food, with maintenance of 24-48 mg daily.
    • Side effects include common or very common gastrointestinal discomfort, headache, nausea, and unknown frequency.
    • Pregnancy should be avoided unless clearly necessary, and breastfeeding should only be used if potential benefit outweighs risk.
    • Clinical and advisory labels include Betahistine dihydrochloride, Serc, and other medications.
    • Available in various dosages, including 8 mg, 16 mg, 24 mg, and 64 mg tablets.
    • Used for treating nausea and labyrinth disorders, BNF 85, and the nervous system.
    • Serc is available in 120 tablets and 16 tablets, with prices ranging from £9.04 to £1.55.

    Pain - General

    • Pain is an unpleasant sensory and emotional experience associated with or resembling tissue damage.
    • It can be neuropathic, nociceptive, or nociplastic and can be acute or chronic, primary or secondary in nature.
    • Chronic pain is defined as pain that has been present for more than 12 weeks beyond the expected time of wound healing.
    • It is a complex phenomenon that can have a considerable impact on quality of life, resulting in significant suffering and disability.
    • Chronic primary pain is defined as pain that has no clear underlying condition or where the pain appears out of proportion to any observable injury or disease.
    • Types of chronic primary pain include complex regional pain syndrome, fibromyalgia, primary headache and orofacial pain, primary visceral, and primary musculoskeletal pain.
    • Secondary pain is caused by an underlying condition and can be organized into six pain categories: cancer-related, neuropathic, post-surgical or post-traumatic, secondary headache or orofacial, secondary musculoskeletal, and secondary visceral.
    • Depression is a common comorbidity in those with chronic pain, and individuals should be monitored and treated for depression as appropriate.
    • Treatment aims to reduce pain and the impact of chronic pain on quality of life, mood, and function.
    • A wide range of both pharmacological and nonpharmacological management strategies are available for chronic pain, with treatment options guided by any known underlying chronic pain condition(s).

    Pain - Treatment

    • Non-drug treatment includes exercise and exercise therapies, with strategies to improve adherence.
    • Transcutaneous electrical nerve stimulation (TENS) may be considered for relief of chronic pain.
    • Referral to a pain management program and psychologically-based interventions such as cognitive behavioral therapy, biofeedback, and progressive relaxation should be considered for patients with chronic pain.
    • Brief education should be given to all patients.
    • Self-management resources should be considered to complement other therapies in the treatment of chronic pain.
    • Chronic pain treatment involves the use of various analgesics, including non-opioid, opioid, and adjuvant analgesics.
    • The WHO analgesic ladder is widely used to guide the basic treatment of acute and chronic pain, although there is little evidence to support its use in chronic pain.
    • Individual responses to analgesia vary considerably, both in terms of efficacy and side-effects.
    • Even with the same chronic pain syndrome, the underlying pain mechanisms may differ between individuals, providing challenges with assessment and management in routine clinical practice.

    Pain - Non-opioid Analgesics

    • Non-opioid analgesics include paracetamol and NSAIDs (in both oral and topical forms).
    • Single-ingredient analgesics are preferred for independent titration, but fixed-dose combination analgesics may be considered for those with stable chronic pain.

    Pain - Opioid Analgesics

    • Opioid analgesics can be divided into those used for mild-to-moderate pain (such as codeine phosphate) and those used for moderate-to-severe pain (such as morphine or oxycodone hydrochloride).
    • Opioids should only be considered in carefully selected individuals for short- to medium-term treatment of chronic non-malignant pain when other therapies have been insufficient.
    • The benefits should outweigh the risks of serious harms (such as addiction, overdose, and death).
    • Prescribers should have knowledge of opioid pharmacology and be competent and experienced in the use of strong opioids.
    • When starting treatment with an opioid, there should be an agreement between the prescriber and patient about the expected outcomes, with advanced agreement on reduction and cessation if these are not met.
    • Opioids should be reviewed at least annually but more frequently if required, considering a gradual reduction to the lowest effective dose or complete cessation.
    • Pain specialist advice or review should be sought for individuals taking doses >90 mg/day morphine equivalent.

    Pain - Adjuvant Analgesics

    • Adjuvant analgesics, such as antidepressants, antiepileptics, benzodiazepines, bone-modulating drugs, corticosteroids, and topical capsaicin, lidocaine, and rubefacients, are used to manage chronic primary pain.
    • Non-opioid drugs like paracetamol and aspirin are suitable for pain in musculoskeletal conditions, while opioid analgesics are more suitable for moderate to severe pain, particularly of visceral origin.

    Pain - MHRA/CHM Information on Opioids

    • The MHRA/CHM have issued important safety information on the use of opioids and the risk of dependence and addiction.

    Pain - Sickle-Cell Disease

    • Pain in sickle-cell disease is managed with paracetamol, a NSAID, codeine phosphate, or dihydrocodeine tartrate.
    • Severe crises may require morphine or diamorphine hydrochloride.
    • Pethidine hydrochloride should be avoided if possible due to its neurotoxic metabolite accumulation and short half-life.

    Pain - Dental Care

    • Analgesics should be used judiciously in dental care as a temporary measure until the cause of the pain has been dealt with.
    • Most dental pain is effectively relieved by non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, diclofenac sodium, and aspirin.
    • Paracetamol has analgesic and antipyretic effects but no anti-inflammatory effect.
    • Opioid analgesics, such as dihydrocodeine tartrate, act on the central nervous system and are traditionally used for moderate to severe pain.
    • Opioid analgesics are relatively ineffective in dental pain and their side-effects can be unpleasant.
    • Combining a non-opioid with an opioid analgesic can provide greater relief of pain than either analgesic given alone, but this applies only when an adequate dose of each analgesic is used.
    • Most combination analgesic preparations have not been shown to provide greater relief of pain than an adequate dose of the non-opioid component given alone, and they have the disadvantage of an increased number of side-effects.
    • Analgesics given before dental procedures should have a low risk of increasing postoperative bleeding.
    • In the case of pain after the dental procedure, taking an analgesic before the local anesthetic has worn off can improve control.
    • Postoperative analgesia with ibuprofen or aspirin is usually continued for about 24 to 72 hours.

    Pain - Temporomandibular Dysfunction

    • Temporomandibular dysfunction can be related to anxiety in some patients who may clench or grind their teeth (bruxism) during the day or night.
    • The muscle spasm may be treated empirically with an overlay appliance which provides a free sliding occlusion and may also interfere with grinding.
    • Diazepam, which has muscle relaxant and anxiolytic properties, may be helpful but should only be prescribed on a short-term basis during the acute phase.
    • Analgesics such as aspirin or ibuprofen may also be required.

    Pain - Dysmenorrhoea

    • Dysmenorrhoea is generally associated with ovulatory cycles and can be prevented with the use of an oral contraceptive.
    • Paracetamol or NSAIDs provide adequate relief of pain, but antiemetics may be needed for vomiting and severe pain associated with dysmenorrhoea in women with endometriosis.

    Pain - Non-Opioid Analgesics - Further information

    • Non-opioid analgesics and compound analgesic preparations are used for headache, transient musculoskeletal pain, dysmenorrhoea, and pyrexia.
    • Aspirin is indicated for headache, transient musculoskeletal pain, dysmenorrhoea, and pyrexia.
    • Paracetamol is similar in efficacy to aspirin but has no demonstrable anti-inflammatory activity; it is less irritant to the stomach and is now generally preferred to aspirin, particularly in the elderly.
    • Nefopam hydrochloride may have a place in the relief of persistent pain unresponsive to other non-opioid analgesics but may cause synapthomimetic and antimuscarinic side-effects.

    Pain - Non-Steroidal Anti-Inflammatory Analgesics (NSAIDs)

    • Non-steroidal anti-inflammatory analgesics (NSAIDs) are particularly useful for the treatment of patients with chronic disease accompanied by pain and inflammation.
    • Some are also used in the short-term treatment of mild to moderate pain including transient musculoskeletal pain, but paracetamol is now often preferred, particularly in the elderly.
    • Selective inhibitors of cyclo-oxygenase-2 may be used in preference to non-selective NSAIDs for patients at high risk of developing serious gastro-intestinal side-effects.
    • Several NSAIDs are also used for postoperative analgesia.

    Pain - Compound Analgesic Preparations

    • Compound analgesic preparations that contain a simple analgesic with an opioid component reduce the scope for effective titration in the management of pain of varying intensity.
    • A full dose of the opioid component in compound analgesic preparations effectively augments the analgesic activity but is associated with the full range of opioid side-effects.
    • It is important to weigh up whether there is a need for a non-opioid and an opioid analgesic to be taken simultaneously when assessing pain.

    Pain - Opioid Analgesics - Further Treatment

    • Opioid analgesics are used to relieve moderate to severe pain, particularly of visceral origin. They can cause dependence and tolerance, but they are not deterrents in the control of pain in terminal illness.
    • Regular use of a potent opioid may be appropriate for certain cases of chronic non-malignant pain.
    • Morphine is the most valuable opioid analgesic for severe pain, although it frequently causes nausea and vomiting. It is the standard against which other opioid analgesics are compared.
    • Morphine is the opioid of choice for the oral treatment of severe pain in palliative care and is given regularly every 4 hours or every 12 or 24 hours as modified-release preparations.
    • Buprenorphine has both opioid agonist and antagonist properties and may precipitate withdrawal symptoms, including pain, in patients dependent on other opioids.
    • It has abuse potential and may itself cause dependence. It has a much longer duration of action than morphine and is effective sublingually for 6 to 8 hours. Unlike most opioid analgesics, the effects of buprenorphine are only partially reversed by naloxone hydrochloride.
    • Dipipanone hydrochloride is less sedating than morphine but the only preparation available contains an antiemetic, making it not suitable for regular regimens in palliative care.
    • Diamorphine hydrochloride (heroin) is a powerful opioid analgesic that may cause less nausea and hypotension than morphine.
    • Alfentanil, fentanyl, and remifentanil are used by injection for intra-operative analgesia.
    • Methadone hydrochloride is less sedating than morphine and acts for longer periods, but should not be administered more than twice daily to avoid accumulation and opioid overdosage.
    • Oxycodone hydrochloride is commonly used as a second-line drug if morphine is not tolerated or does not control the pain.
    • Codeine phosphate is a weak opioid used for mild to moderate pain relief, similar to dihydrocodeine tartrate. Higher doses may provide additional pain relief but may result in more nausea and vomiting.
    • Meptazinol has a low incidence of respiratory depression and a reported length of action of 2 to 7 hours.

    Pain - Postoperative Analgesia

    • Postoperative analgesia can be managed using a multimodal approach using a combination of analgesics from different classes.
    • Intra-operative opioids affect the prescribing of postoperative analgesics, and a postoperative opioid analgesic should be given with care as it may potentiate residual respiratory depression.
    • Morphine is the most widely used opioid, while Tramadol hydrochloride is less effective in severe pain.
    • Buprenorphine may antagonize the analgesic effect of previously administered opioids and is generally not recommended.
    • Pethidine hydrochloride is generally not recommended for postoperative pain due to its metabolization to norpethidine, which may accumulate in renal impairment and stimulate the central nervous system.
    • Opioids are also given epidurally in the postoperative period but are associated with side-effects such as pruritus, urinary retention, nausea, and vomiting.
    • Patient-controlled analgesia (PCA) can be used to relieve postoperative pain.

    Pain - Penthrox®

    • The manufacturer of Penthrox®, a non-opioid medication, advises that it should only be self-administered under the supervision of personnel experienced in its use, using a hand-held Penthrox® inhaler device.
    • It has been indicated for moderate-to-severe pain associated with trauma and is recommended for adults to administer 3-6 mL as required, avoid administration on consecutive days, and administer using an inhaler device.
    • The contra-indications include cardiovascular disease, liver damage, impaired consciousness, respiratory depression, susceptibility to malignant hyperthermia, and contraindications for elderly individuals, repeated administration more than once every three months, increased risk of hepatic injury, and risk factors for renal impairment. ### Methoxyflurane
    • Dizziness, drowsiness, dry mouth, headache, nausea, anxiety, increased appetite, chills, impaired concentration, cough, depression, fatigue, feeling abnormal, flushing, hyperhidrosis, hypertension, hypotension, memory loss, altered mood, oral disorders, paraesthesia, peripheral neuropathy, speech impairment, altered taste, vision disorders, and vomiting are side effects.
    • Methoxyflurane should be used with caution in pregnancy, breastfeeding, hepatic impairment, renal impairment, and allergy.
    • Methoxyflurane contains butylated hydroxytoluene, which may contain Butylated hydroxytoluene.

    Penthrox

    • Penthrox inhalation vapor is available in 3 ml bottles with a device for £18.46 (hospital only).

    Paracetamol

    • Treats mild to moderate pain, pyrexia with discomfort, post-immunization pyrexia in infants, and acute migraine
    • Administered by dental practitioners’ formulary, orally, through suspension, or rectal suppositories.
    • Not licensed for use in children under 16 years and is not used as prophylaxis of post-immunization pyrexia following immunisation with meningococcal group B vaccine.
    • Patients should be advised on the appropriate inhaler technique and a patient alert card should be provided.
    • Rare or very rare side effects include thrombocytopenia.
    • Specific side effects include anorectal erythema, hypersensitivity, hypotension, leucopenia, malaise, neutropenia, angioedema, liver injury, severe cutaneous adverse reactions (SCARs), skin reactions, flushing, skin reactions, tachycardia, granulocytosis, bronchospasm, hepatic function abnormal, rash, severe cutaneous adverse reactions (SCARs), and blood disorder.
    • Overdose can cause liver damage and less frequently renal damage.
    • Pregnancy is not known to be harmful, and breastfeeding is too small to be harmful.
    • Clinical judgment should be used to adjust the dose of oral and intravenous paracetamol in patients with a body-weight under 50 kg or those with risk factors for hepatotoxicity.

    Nefopam Hydrochloride

    • Recommended for moderate pain in adults and the elderly and is a non-opioid centrally acting drug.
    • Side effects include coma, drowsiness, headache, hyperhidrosis, insomnia, tachycardia, blurred vision, vomiting, rare or very rare urine discoloration, abdominal pain, angioedema, confusion, diarrhea, dizziness, dry mouth, gastrointestinal disorder, hallucination, hypotension, nausea, nervousness, palpitations, paraesthesia, seizure, syncope, tremor, urinary retention, and pregnancy.

    Aspirin with codeine

    • Used with caution in treating mild to moderate pain and pyrexia.
    • Adults should take 1–2 tablets every 4–6 hours as required, with a maximum of 8 tablets per day.

    Opioids

    • MHRA has issued a warning about the potential risks associated with co-prescription of opioids with benzodiazepines and benzodiazepine-like drugs.
    • Co-prescription of opioids with benzodiazepines and benzodiazepine-like drugs can lead to additive CNS depressant effects, increasing the risk of sedation, respiratory depression, coma, and death.
    • Healthcare professionals should only co-prescribe if there is no alternative and to administer the lowest possible doses for the shortest duration.
    • Patients should be closely monitored for signs of respiratory depression at treatment initiation and when there is any change in prescribing, such as dose adjustments or new interactions.
    • If methadone is coprescribed with a benzodiazepine or benzodiazepine-like drug, the respiratory depressant effect of methadone may be delayed, and patients should be monitored for at least two weeks after initiation or changes in prescribing.
    • Patients should be informed of the signs and symptoms of respiratory depression and sedation and advised to seek urgent medical attention if these occur.
    • New safety recommendations have been issued following a review of the risks of dependence and addiction associated with prolonged use of opioids for non-malignant pain.
    • Healthcare professionals are advised to discuss with patients that prolonged use of opioids, even at therapeutic doses, may lead to dependence and addiction.
    • Healthcare professionals should agree a treatment strategy and plan for the end of treatment with the patient before starting opioids.
    • Patients and their carers should be counseled on the risks of tolerance and potentially fatal unintentional overdose, as well as signs and symptoms of overdose.
    • Healthcare professionals should provide regular monitoring and support to patients at increased risk, such as those with current or history of substance use disorder (including alcohol misuse) or mental health disorders.
    • Opioid dosage should be gradually tapered at the end of treatment.
    • Consider hyperalgesia in patients on long-term opioid treatment who present with increased pain sensitivity.
    • Contra-indications include acute respiratory depression, comatose patients, head injury, raised intracranial pressure, and risk of paralytic ileus.
    • Cautions include adrenocortical insufficiency, asthma, central sleep apnoea, convulsive disorders, current or history of mental health disorder, current or history of substance use disorder, debilitated patients, diseases of the biliary tract, elderly, hypotension, hypothyroidism, impaired respiratory function, inflammatory bowel disorders, myasthenia gravis, obstructive bowel disorders, prostatic hypertrophy, shock, urethral stenosis.
    • Opioids cause a dose-dependent increased risk of central sleep apnea, so total opioid dose reduction is recommended.
    • Palliative care should not necessarily be a deterrent to the use of opioid analgesics in terminal illness.
    • Elderly prescriptions may be potentially inappropriate, especially if prescribed a strong, oral or transdermal opioid (morphine, oxycodone, fentanyl, buprenorphine, diamorphine, methadone, tramadol, pethidine, and pentazocine) as first-line therapy for formild pain.
    • Overdose opioids can cause coma, respiratory depression, and pinpoint pupils.
    • In pregnancy, respiratory depression and withdrawal symptoms can occur in the neonate if opioid analgesics are used during delivery.
    • Treatment should avoid abrupt withdrawal after long-term treatment and be withdrawn gradually to avoid abstinence symptoms.
    • The Faculty of Pain Medicine has created resources for healthcare professionals regarding opioid prescribing.
    • Drowsiness may affect the performance of skilled tasks, and the effects of alcohol are enhanced.
    • Driving at the start of therapy with opioid analgesics and following dose changes should be avoided.

    Buprenorphine

    • Opioid-receptor partial agonist with opioid agonist and antagonist properties.
    • Indicated for moderate to severe pain by simultaneous administration in children (body-weight 16-25 kg), infants (body-weight 25-37.5 kg), children (body-weight 37.5-50 kg), and adults (body-weight 50 kg and above).
    • Premedication is recommended for both simultaneous and intra-operative analgesia.
    • Adjuncts in the treatment of opioid dependence should use sequential tables for dosage adjustments.
    • Adults should start with 0.8-4 mg for 1 dose on the first day, adjusted in steps of 2-4 mg daily if required.
    • Intrana-operative analgesia should be administered by slow intravenous injection, with a maximum of 18 mg per day.
    • Moderate to severe chronic pain unresponsive to nonopioid analgesics in opioid-naïve patients should be administered on expert advice.
    • Transdermal application using patches should be used for initial doses of 5 micrograms/hour.
    • If necessary, dose should be adjusted at intervals of at least 3 days.
    • Pharmacokines should be evaluated after the system has been worn for at least 3 days to allow for gradual increase in plasma-buprenorphine concentration.
    • For 4-day patches, the analgesic effect should be evaluated after the system has been worn for at least 1 day to allow for gradual increase in plasma-buprenorphine concentration.
    • Buvidal® is an adjunct in the treatment of opioid dependence (under expert supervision) and can be used by subcutaneous injection in adults.
    • Buvidal® injections are available in various strengths, with weekly and monthly injections having a terminal half-life of 3 to 5 days. Monthly injections have a half-life of 19 to 25 days.
    • SIXMO® is an adjunct in the treatment of opioid dependence in clinically stable patients who require no more than 8 mg per day of sublingual buprenorphine.
    • For subcutaneous injection, adults aged 18-65 years should receive 296.8 mg, consisting of 4 implants containing 74.2 mg to be left in place for 6 months.
    • Sublingual buprenorphine should be discontinued 12 to 24 hours prior to insertion for supplemental sublingual buprenorphine, treatment discontinuation, and re-treatment.
    • Unlicensed use of buprenorphine transdermal patches is not recommended, as they may differ from licensed doses provided in the BNF for chronic pain.
    • Sublingual tablets are not licensed for use in children under 6 years.
    • Contra-indications include SIXMO® contra-indications for magnetic resonance imaging (MRI) and history of keloid or hypertrophic scar formation.
    • Specific contra-indications include fever or external heat, other opioids should not be administered within 24 hours of patch removal, and when used for adjunct in the treatment of opioid dependence.
    • Increased side-effects of buprenorphine transdermal patches include anxiety, depression, diarrhea, tremor, appetite abnormality, asthenia, chills, gastrointestinal discomfort, hot flush, increased risk of infection, malaise, pain, procedural pain, sleep disorders, chest pain, chills, cough, dysmenorrhoea, dyspnoea, eye disorders, fever, gastrointestinal discomfort, gastrointestinal disorders, hypersensitivity, hypotension, increased risk of infection, insomnia, lymphadenopathy, malaise, migraine, muscle complaints, muscle tone increased, pain, paraesthesia, peripheral oedema, speech disorder, syncope, thinking, and susceptibility to QT-interval prolongation.
    • Interactions with buvidal include general side-effects such as anxiety, depression, diarrhea, tremor, and specific side-effects like appetite decreased, asthenia, dyspnoea, gastrointestinal discomfort, muscle weakness, oedema, sleep disorders, and cold sweat, dehydration, device complications, dysmenorrhoea, eye disorders, feeling cold, fever, flatulence, haematochezia, irritability, joint disorders, level of consciousness decreased, limb discomfort, lymphadenopathy, migraine, muscle spasms, neutropenia, oedema, post procedural complication, sensation abnormal, sexual dysfunction, swelling, thinking abnormal, urinary disorders, vision blurred, weight changes, yawning, with parenteral use, procedural dizziness, and sublingual use.
    • Buprenorphine is a medication used to treat opioid dependence, which can cause various side effects such as abnormal heartbeats, dyspepsia, dyspnoea, hypertension, pallor, paraesthesia, psychosis, seizures, speech slurred, tinnitus, urinary disorders, vision disorders, weight decreased, and more.
    • It is also used in transdermal form for aggression, chest pain, chills, circulation collapse, impaired concentration, cough, dry eye, fever, gastrointestinal disorders, hiccups, hypertension, hypotension, injury, memory loss, migraines, altered mood, movement disorders, muscle complaints, respiratory disorders, abnormal sensation, sexual dysfunction, speech impairment, syncope, altered taste, tinnitus, urinary disorders, vision disorders, weight decreased, and rare or very rare.
    • With sublingual use, buprenorphine can cause angioedema, bronchospasm, angina pectoris, asthma exacerbated, dehydration, dysphagia, ear pain, eyelid oedema, increased risk of infection, influenza-like illness, muscle contractions involuntary, psychotic disorder, vasodilation, and other side effects.
    • It is also used by implant for hepatic disorders and hepatic encephalopathy.
    • Pregnancy with buprenorphine is advised to avoid due to inflexible dosing of preparation.
    • Breast feeding is present in low levels in breast milk and neonates should be monitored for drowsiness, adequate weight gain, and developmental milestones.
    • Manufacturers advise caution in severe impairment and consider avoiding transdermal patches in severe impairment.
    • Dose adjustments are advised for oral lyophilisate in adults and renal impairment in some manufacturers.
    • Pre-treatment screening is recommended before commencing therapy for opioid dependence.
    • Monitoring requirements include monitoring liver function, with baseline tests recommended before beginning therapy and regular tests performed throughout treatment.
    • For subcutaneous implants, monitoring for signs of infection and problems with wound healing is recommended.
    • Transdermal buprenorphine patches are not suitable for acute pain or patients whose analgesic requirements are changing rapidly due to the long time to steady state.
    • Prescribers and dispensers must ensure that the correct preparation is prescribed and dispensed, with brand name prescriptions recommended to reduce confusion and errors.
    • Espranor oral lyophilisate has different bioavailability to other buprenorphine products and is not interchangeable with them.
    • Sixmo® patients previously treated with sublingual buprenorphine or sublingual buprenorphine with naloxone must be on stable daily buprenorphine doses of 2 to 8mg for at least 30 days before switching to the Sixmo® subcutaneous implant.
    • Educational risk minimization materials for Sixmo® subcutaneous implant are available for healthcare professionals.
    • Patients or carers should be advised on how to administer buprenorphine products, and for subcutaneous implant patients and carers should seek immediate medical attention if spontaneous expulsion occurs.
    • Spontaneous expulsion requires immediate medical attention for subcutaneous implant patients.
    • A patient alert card should be provided for subcutaneous implant patients.
    • Driving and skilled tasks should be counseled on the risk of somnolence lasting for up to one week after insertion.
    • National funding/access decisions for buprenorphine include Methadone and buprenorphine for the management of opioid dependence (January 2007).
    • Scottish Medicines Consortium (SMC) decisions recommend buprenorphine transdermal patches (Butec®) for the treatment of chronic non-malignant pain of moderate intensity when an opioid is necessary for obtaining adequate analgesia in adults (January 2017).
    • Buprenorphine oral lyophilisate (Espranor®) is recommended with restrictions.
    • Buprenorphine (Buvidal®) is recommended with restrictions.
    • Buprenorphine implant (Sixmo®) is recommended.
    • Medicinal forms for buprenorphine can vary in licensing. Solutions for injection include Temgesic (Indivior UK Ltd), sublingual tablets (Natzon, Natzon, Prefibin, Subutex, Temgesic, Sixmo, BuTrans, Bunov), and injectable devices like Sixmo (Accord Healthcare Ltd).
    • Transdermal patch solutions include BuTrans (5 micrograms/hour), BuTrans (10 micrograms/hour), Bunov (20 micrograms/hour), and Bunov (Glenmark Pharmaceuticals).

    Buprenorphine Products

    • Buprenorphine products are used to manage moderate chronic non-malignant pain.
    • The National Institute of Clinical Excellence (NICE) recommends methadone and buprenorphine for opioid dependence management.
    • The Scottish Medicines Consortium (SMC) and All Wales Medicines Strategy Group (AWMSG) recommend buprenorphine implants and injections.

    Medication for Opiate Use

    • Medications include Bunov, Bupeaze, Butec, Carlosafine, Hapoctasin, Panitaz, Rebrikel, Reletrans, Relevtec, Sevodyne, and Transtec.
    • Butec is a cost-effective option, priced at £7.92 DT.
    • Each medication has specific benefits and risks.

    Buprenorphine Hydrochloride and Paracetamol

    • Available in various dosages and forms.
    • The drug properties are specific to the combination only.

    Co-codamol

    • A mixture of codeine phosphate and paracetamol.
    • The proportions are expressed as x/y, where x and y are the strengths of codeine phosphate and paracetamol in milligrams.
    • When no strength is stated, tablets, dispersible tablets, or capsules containing 8mg codeine phosphate and 500mg paracetamol should be dispensed.
    • The Drug Tariff allows tablets labelled 'dispersible' to be dispensed against an order for 'effervescent' and vice versa.
    • Less suitable for prescribing, but can be sold to the public under certain circumstances.
    • Not recommended for adolescents (12-18 years) with breathing problems.
    • Contraindicated in patients with acute ulcerative colitis, antibiotic-associated colitis, abdominal distention, or conditions requiring avoidance of peristalsis inhibition.
    • Cautions include acute abdomen, alcohol dependence, cardiac arrhythmias, chronic alcoholism, chronic dehydration, and chronic malnutrition.
    • Ultra-rapid codeine metabolisers (CYP2D6 ultrarapid metabolizers) can experience increased morphine toxicity, while poor metabolizers have reduced therapeutic effect.
    • Interactions with paracetamol include abdominal pain, addiction, agranulocytosis, blood disorder, irritability, pancreatitis, restlessness, severe cutaneous adverse reactions (SCARs), thrombocytopenia, and overdose liver damage (and less frequently renal damage).
    • Manufacturers advise against breastfeeding due to codeine presence in milk.
    • Caution is advised in mild to moderate hepatic impairment, while severe impairment should be avoided.

    Codeine Phosphate

    • Used for relieving acute moderate pain in children over 12 years, if other painkillers like paracetamol or ibuprofen are ineffective.
    • Not recommended for children with compromised breathing, including those with neuromuscular disorders, severe cardiac or respiratory conditions, respiratory infections, multiple trauma, or extensive surgical procedures.
    • MHRA/CHM Advice (July 2013) emphasizes limited use in children over 12 years for acute moderate pain, only when other painkillers are ineffective.
    • Significant risk of serious and life-threatening adverse reactions has been identified in children with obstructive sleep apnoea who received codeine after tonsillectomy or adenoidectomy.
    • Contraindicated in all children (under 18 years) who undergo tonsil or adenoid removal for sleep apnoea treatment.
    • Maximum daily dose for children aged 12-18 years is 240 mg.
    • Lowest effective dose should be used, and treatment duration limited to three days.
    • Also contraindicated in patients of any age with a history of severe pain or severe bleeding.
    • Available in tablets, capsules, oral solutions, and combinations.
    • Dosages vary by patient location and age.
    • Side effects include abdominal cramps, addiction, decreased appetite, biliary spasm, depression, dyskinesia, dyspnoea, face oedema, fatigue, fever, hyperglycaemia, hypersensitivity, hypotension, hyperothermia, intracranial pressure increased, lymphadenopathy, malaise, mood altered, muscle rigidity, nightmare, pancreatitis, postural hypotension, restlessness, seizure, sexual dysfunction, splenomegaly, ureteral spasm, urinary disorders, and vision disorders.
    • Manufacturer advises against breastfeeding due to varying codeine metabolising capacities.
    • Caution in mild to moderate hepatic impairment, avoid in severe impairment.
    • Dose adjustments should be considered in mild to moderate renal impairment.

    Dihydrocodeine Tartrate

    • A non-proprietary medication that can cause delayed gastric emptying, phaeochromocytoma, and other side effects like CNS depression, severe cor pulmonale, severe diarrhea, and toxic psychosis.
    • Side effects include biliary spasm, circulatory depression, increased intracranial pressure, mood altered, and postural hypotension.
    • Therapeutic doses unlikely to affect infants.
    • Withdrawal symptoms in infants of dependent mothers is not a suitable treatment for dependency.
    • Manufacturer advises caution and dose adjustments; avoid in renal impairment.
    • Available from special-order manufacturers in solution for injection, powder for solution for injection, and DF118 Forte®.

    Dihydrocodeine with Paracetamol

    • MHRA advises prescribing and dispensing by strength to minimize errors and opioid overdose risk.
    • Less suitable for prescribing.
    • Available from special-order manufacturers as oral suspension and oral solution.

    Fentanyl

    • Fentanyl films are not bioequivalent to other fentanyl preparations and are not interchangeable for the treatment of breakthrough pain.
    • Weight-based doses may be needed for obese patients to avoid excessive dosage.

    Transdermal Fentanyl Patches

    • Can lead to lethargy and fatal opioid toxicity from accidental exposure, particularly in children.
    • MHRA advises that fentanyl patches are contraindicated in opioid-naive patients.
    • Other analgesics and opioids should be considered for non-malignant pain before prescribing fentanyl patches.
    • Contraindications include transdermal use in opioid-naive patients, Bradyarrhythmias, cerebral tumors, diabetes mellitus, impaired consciousness, mucositis.
    • Common side effects include apnea, hypertension, hypotension, movement disorders, muscle rigidity, post-procedural complications, respiratory disorders, vascular pain, visual impairment, asthenia, dyspnoea, oral disorders, anxiety, appetite decreased, asthenia, depression, diarrhoea, dyspnoea, gastrointestinal discomfort, hypertension, insomnia, malaise, muscle complaints, peripheral oedema, sensation abnormal, temperature sensation altered, tremor, and vision blurred.
    • Uncommon side effects include airway complication of anaesthesia, chills, hiccups, hypothermia, altered smell sensation, anxiety, appetite decreased, bruising tendency, concentration impaired, depression, emotional lability, erectile dysfunction, gastrointestinal discomfort, hypotension, impaired gastric emptying, joint disorders, malaise, memory loss, musculoskeletal stiffness, night sweats, numbness, oropharyngeal pain, overdose, paranoia, psychiatric disorder, sleep disorders, taste altered, throat tightness, tremor, vision blurred, consciousness impaired, cyanosis, fever, gastrointestinal disorders, hypotension, influenza-like illness, memory loss, respiratory disorders, seizures, sexual dysfunction, vision blurred.
    • Rare or very rare side effects include respiratory depression, coma, death, and central nervous system stimulation.
    • Intravenous fentanyl can cause muscle rigidity, particularly in the thoracic muscles.
    • Slow intravenous injection is advised.
    • Higher doses may require premedication with benzodiazepines and muscle relaxants.

    Post-administration Considerations

    • Manufacturers advise against breastfeeding during treatment and for 24 hours after the last administration.
    • Caution is advised in patients with hepatic or renal impairment.

    Administration Directions

    • Apply patches to dry, non-irritated, non-irradiated, non-hairy skin on the torso or upper arm.

    • Remove after 72 hours.

    • Replace patches on a different area.

    • For intravenous use, give glucose 5% or sodium chloride 0.9% continuously or intermittently.

    • For buccal use in adults, moisten the mouth, place film on inner lining of the cheek, hold for at least 5 seconds until it sticks, and leave to dissolve (15-30 minutes).### Fentanyl Patches

    • Prescriptions for fentanyl patches should specify the release rate and dosage interval.

    • The total quantity of patches should be written in words and figures.

    • Patients and caregivers should be informed about proper administration and disposal of fentanyl patches.

    • They should also be aware of opioid overdose symptoms and seek immediate medical attention if these occur.

    • Fentanyl is available in various presentations: transdermal patches, buccal films, lozenges, and nasal spray.

    • Fentanyl nasal spray is recommended for breakthrough pain in adults on chronic opioid therapy for cancer pain.

    • Other forms include solutions for injection, infusion, and buccal tablets.

    Oral and Transdermal Fentanyl Medications

    • Fentanyl is available in various dosages for sublingual tablets and transdermal patches.
    • Transdermal patches include Durogesic DTrans, Mezolar Matrix, and Opiodur.

    Hydromorphone Hydrochloride

    • Used for severe pain in cancer patients.
    • Available in immediate-release and modified-release capsules for children aged 12-17 years.
    • Contraindicated in acute abdominal pain and certain nervous system conditions.
    • Side effects include abdominal pain, anxiety, decreased appetite, asthenia, sleep disorders, depression, diarrhea, dyspnea, erectile dysfunction, hypotension, malaise, movement disorders, paresthesia, peripheral edema, altered taste, tremor, visual impairment, hyperalgesia, paralytic ileus, seizure, and withdrawal syndrome in neonates.
    • Caution is advised for hepatic impairment and renal impairment, with dose adjustments necessary.

    Morphine

    • Used for moderate to severe pain in various presentations: oral solution, modified-release capsules, and intravenous injection.
    • Contraindicated in myocardial infarction and pheochromocytoma.
    • Side effects include diarrhea, gastrointestinal discomfort, and uncommon hypotension.
    • Overdose effects can be partially reversed by naloxone.
    • Caution is advised for hepatic impairment, and dose adjustments are necessary for renal impairment.

    Meptazinol

    • Used for pain management in children and adults.
    • Available in solution for injection and modified-release formulations.
    • Dosage varies depending on age, pain severity, and patient response.
    • Modified-release formulations are used for pain management affecting the brain and heart.

    Morphine in Palliative Care

    • Different dosage requirements for opioid-naïve patients, those switching from weak opioids, and for breakthrough pain.
    • Modified-release 12-hourly preparations are not licensed for use in children, and suppositories are not licensed for rectal use.
    • Caution is advised for acute impairment and dose adjustments may be required.
    • Renal impairment should be avoided as it can increase and prolong opioid effects.

    Morphine Administration

    • Prescriptions must specify the form of morphine medication for oral and rectal use.
    • Modified-release preparations are available in 12-hourly and 24-hourly formulations.
    • Rectal suppositories require specific strength and morphine salt information.
    • Legal category exceptions exist for morphine oral solutions.

    Morphine Medications

    • Various oral, injection, and modified-release forms are available.
    • Modified-release tablets include MST Continus, Morphgesic SR, Sevredol, and Zomorph.
    • Solutions for injection include Morphine (Non-proprietary), Morphine sulfate, and Zomorph.

    Opioid Cautionary Labels

    • Provide information on various opioid medications, including Morphine, Oramorph, Actimorph, and Oxycodone hydrochloride.

    Oxycodone Hydrochloride

    • Used for postoperative pain and severe pain.
    • Available in immediate-release and modified-release formulations.
    • Patient-controlled analgesia (PCA) is another medication used for pain relief.
    • Onexila XL® is a medication for severe pain in adults.

    Opioid Side Effects

    • General side effects include anxiety, depression, diarrhea, dyspnea, gastrointestinal discomfort, hiccups, mood alteration, tremor, biliary colic, belching, chills, dehydration, dysphagia, gastrointestinal disorders, malaise, memory loss, neuromuscular dysfunction, edema, seizures, abnormal sensation, sexual dysfunction, speech disorder, syncope, altered taste, thirst, vasodilation, visual impairment, hypotension, aggression, amenorrhea, and cholesterol alterations.
    • Oral use commonly leads to abnormal appetite, asthenia, cognitive impairment, insomnia, movement disorders, altered perception, psychiatric disorders, increased urinary frequency, decreased appetite, asthenia, cough, sleep disorders, and abnormal thinking.

    Oxycodone Medications

    • Various modified-release medications are available, including Ixyldone, Leveraxo, Longtec, Oxeltra, and OxyContin.

    Other Oxycodone Medications

    • A list of medications available for pain management includes Oxylan, Oxypro, Reltebon, Renocontin, and Oxycodone hydrochloride.
    • Oxycodone hydrochloride is also available in oral solutions.

    Oxycodone Hydrochloride for Restless Legs Syndrome

    • Used in combination with naloxone for symptomatic severe to very severe idiopathic restless legs syndrome.
    • Dosage is adjusted weekly according to response, with a maximum of 60/30 mg per day.
    • Patients already receiving opioid analgesics may start with a higher dose.

    Oxycodone Hydrochloride

    • For moderate to severe pain, dosage is 50 mg every 3-4 hours, taken preferably after food, 25-100 mg usual dose, maximum 600 mg per day.
    • For moderate pain, dosage is 30 mg every 3-4 hours as required.
    • For severe pain, dosage is 45-60 mg every 3-4 hours as required.
    • Used in combination with naloxone for severe to very severe idiopathic restless legs syndrome.
    • Dosage adjusted weekly based on response, expressed in milligrams of oxycodone/naloxone as x/y.

    Pethidine Hydrochloride (Meperidine)

    • Used for acute pain, heart failure, and chronic lung disease.
    • A range of side effects, including biliary spasm, blood disorder, chills, circulatory depression, face edema, facial plethora, generalized tonic-clonic seizure, hypertension, hypotension, hypothermia, intracranial pressure increased, mood altered, myalgia, paraesthesia, sexual dysfunction, sleep disorders, syncope, toxic epidermal necrolysis, tremor, ureteral spasm, visual impairment, and overdose effects only partially reversed by naloxone.
    • In severe impairment, dose should be reduced due to increased bioavailability risk.
    • In renal impairment, dose should be reduced due to the risk of increased and prolonged effects.
    • Maximum dosage of 50-100 mg for adults and 25-100 mg for debilitated patients.

    Pentazocine

    • Less suitable for prescribing due to limited information available.
    • Dose should be reduced in severe impairment due to increased bioavailability risk.
    • Dose should be reduced in renal impairment due to increased and prolonged effects.
    • Less suitable for prescribing due to variations in the licensing of different medicines containing the same drug.

    Tapentadol (Palexia ®)

    • Used to manage moderate to severe acute pain in adults.
    • Immediate-release medications start with 50 mg every 4-6 hours, adjusted according to response.
    • Maximum dosage is 700mg in the first 24 hours, and 600mg per day.
    • Severe chronic pain can be managed only with opioid analgesics.
    • Modified-release medications recommended for adults, starting with 50 mg every 12 hours, adjusted according to response, and a maximum of 500 mg per day.
    • Can induce seizures and should be prescribed with caution in patients with a history of seizure disorders or epilepsy.
    • Seizure risk may be increased in patients taking other medicines that lower the seizure threshold.
    • Serotonin syndrome has been reported when used in combination with serotonergic antidepressants.
    • Withdrawal of the serotonergic medicine, along with supportive symptomatic care, usually brings about a rapid improvement in serotonin syndrome.

    Tramadol Hydrochloride

    • Used to treat moderate to severe pain caused by intravenous injection, intravenous infusion, or subcutaneous injection.
    • Recommended for adults to take 50-100 mg every 4-6 hours, with an intravenous injection given over 2-3 minutes.
    • Maximum dosage is 400 mg/24 hours.
    • For children 12-17 years, the dosage is 100 mg, then 50-100 mg every 4-6 hours, with an intravenous injection given over 2-3 minutes.
    • Not suitable for narcotic withdrawal treatment.
    • Cautions include excessive bronchial secretions, history of epilepsy, impaired consciousness, postoperative use in children, susceptibility to seizures, and variation in metabolism.
    • Extreme caution when using for postoperative pain relief in children due to rare but life-threatening adverse events.

    Migraine, Cluster Headache, and Other Trigeminal Autonomic Cephalalgias

    • Cluster headache is a common type of primary headache disorder characterized by recurrent attacks of typically moderate to severe headaches that usually last between 4–72 hours.
    • Migraine is subdivided into migraine with or without aura, and is defined as either episodic or chronic.
    • Medication overuse headache is a complication of migraine.
    • Prophylaxis of cluster headache is considered if the attacks are frequent, last over 3 weeks, or if they cannot be treated effectively.
    • Acute migraine treatment aims to stop the attack or reduce its severity.
    • Preventative treatment focuses on reducing the frequency, severity, and duration of migraine attacks and the development of medication-overuse headache.
    • Lifestyle advice includes regular meals, adequate hydration, sleep, and exercise, as well as avoiding triggers such as stress, relaxation after stress, certain foods and drinks, and bright lights.
    • Monotherapy with either aspirin, ibuprofen, or a 5HT1-receptor agonist (triptan) is recommended as first-line treatment for acute migraine.
    • Antiemetics like metoclopramide hydrochloride or prochlorperazine can also be given as a single dose at the onset of migraine symptoms.
    • Preventative migraine treatment should be based on the impact of the migraine on the patient's quality of life.
    • Propranolol hydrochloride is the firstline preventative treatment for patients with episodic or chronic migraine.
    • If propranolol is unsuitable, other beta-blockers such as metoprolol tartrate, atenolol, nadolol, and timolol maleate can be considered.
    • Topiramate can be given if a beta-blocker is unsuitable.
    • Amitriptyline hydrochloride is effective for migraine prophylaxis.
    • Candesartan cilexetil can be considered in patients with episodic or chronic migraine.
    • Sodium valproate can also be considered in patients with episodic or chronic migraine.
    • Preventative treatment should be tried for at least three months before deciding whether or not it is effective.
    • A good response to treatment is defined as a 50% reduction in the severity and frequency of migraine attacks.
    • Medication overuse should be addressed in patients overusing acute treatments.

    Further Medications

    • Isometheptene is a non-steroidal antiinflammatory drug that can be used to treat various conditions.
    • The combination of Isometheptene with paracetamol is less suitable for prescribing due to more effective treatments available.
    • Aspirin with metoclopramide can cause severe extrapyramidal effects.
    • Treatment with Aspirin with metoclopramide should not exceed three months due to the risk of tardive dyskinesia.

    Isometheptene

    • Side effects can include granulocytosis, angioedema, aplastic anemia, asthma, confusion, constipation, Crohn's disease aggravated, depression, diarrhea, dizziness, drowsiness, dyspnoea, dysuria, euphoric mood, fatigue, fertility decreased female, gastrointestinal discomfort, gastrointestinal disorders, haemolytic anemia, haemorrhage, hallucination, headache, heart failure, hepatic disorders, hypersensitivity, hypertension, increased risk of arterial thromboembolism, malaise, meningitis aseptic, nausea, nephritis tubulointerstitial, nephropathy, neutropenia, oedema, optic neuritis, oral ulceration, pancreatitis, paraesthesia, photosensitivity reaction, renal failure, respiratory disorders, severe cutaneous adverse reactions (SCARs), skin reactions, thrombocytopenia, tinnitus, tremor, vertigo, visual impairment, and vomiting.
    • Patient and caregiver advice is advised for proper dosing and prescribing of Isometheptene with paracetamol.

    Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

    • Used to treat various conditions, including asthma, angioedema, urticaria, and rhinitis.
    • Side effects include fatigue, hypersensitivity, and nausea.
    • Contraindicated in patients with a history of hypersensitivity to aspirin or any other NSAID, which includes those in whom attacks of asthma, angioedema, urticaria, or rhinitis have been precipitated by aspirin or any other NSAID.
    • Long-term use associated with reduced female fertility, which is reversible on stopping treatment.
    • Pregnancy should be avoided unless the potential benefit outweighs the risk, especially during the third trimester.
    • Breast feeding should be done with caution due to the small amount of medication being harmful.
    • Manufacturers advise caution in mild to moderate hepatic impairment and avoid in severe impairment.
    • Renal impairment is generally advised to avoid where possible; if necessary, use with caution.

    Migraleve®

    • Acute migraine medication for children aged 12-15 years.
    • Dosages range from 1 tablet to 6 tablets per 24 hours.

    Eptinezumab

    • Human monoclonal antibody that binds to the calcitonin gene-related peptide (CGRP) ligand.
    • Inhibits the function of CGRP at its receptor, thereby preventing migraine attacks.
    • Prophylaxis of migraine is initiated by a specialist in patients with at least 4 migraine days per month.
    • Adults should take 100 mg every 12 weeks, increased to 300 mg every 12 weeks if necessary.
    • Treatment reviewed 6 months after initiation.
    • Side effects include fatigue, hypersensitivity, and nasal congestion.
    • Pregnancy should be avoided due to limited information available.
    • Breast feeding should be done only if clinically needed.

    Erenumab

    • Prescribed and dispensed by brand name.
    • Stored in a refrigerator (2-8°C) and protected from light.
    • Manufacturer advises recording the brand name and batch number after each administration.
    • Available as Vyepti (Lundbeck Ltd) 100 mg per 1 ml and Aimovig (Novartis Pharmaceuticals UK Ltd) 70 mg per 1 ml solution for injection pre-filled pens.
    • Side effects include constipation, muscle spasms, skin reactions, oedema, and swelling.
    • Pregnancy is advised to avoid due to limited information available.
    • Manufacturer recommends injecting into the abdomen, thigh, or upper arm for migraine prevention.
    • Patients self-administer Aimovig® after appropriate training in subcutaneous injection technique.
    • There are no national funding/access decisions for Erenumab for migraine prevention, but it has been recommended by the National Institute of Health (NICE) and the Scottish Medicines Consortium (SMC).

    Fremanezumab

    • Humanized monoclonal antibody that binds to the CGRP ligand.
    • Inhibits the function of CGRP at its receptor, and thereby preventing migraine attacks.
    • Adults should take 225 mg once a month or 675 mg every 3 months.
    • Treatment reviewed within the first 3 months and regularly thereafter.
    • There are potential risks associated with Eptinezumab, including major cardiovascular disease and side effects like hypersensitivity.
    • Pregnancy is advised to avoid due to limited information available.
    • Breastfeeding is advised to avoid during the first few days after birth due to potential antibody transfer to the infant.
    • Prescribed and dispensed by brand name.
    • Manufacturer advises recording the brand name and batch number after each administration.
    • Stored in a refrigerator (2-8°C) and protected from light.
    • Patients and their carers should be given training in subcutaneous injection technique if appropriate.

    Galcanezumab

    • Humanised monoclonal antibody that binds to the calcitonin gene-related peptide (CGRP) ligand.
    • Inhibits the function of CGRP at its receptor, and thereby preventing migraine attacks.
    • Loading dose 240 mg for 1 dose, then maintenance 120 mg once a month.
    • Review 3 months after initiation.
    • Side effects include common or very common constipation, skin reactions, vertigo, and rare or very rare anaphylactic reaction or angioedema.
    • Manufacturer advises avoidance during pregnancy due to limited information available.
    • Breastfeeding is advised during the first few days after birth, only if clinically needed.
    • Injection into the abdomen, thigh, back of the upper arm, or gluteal region is advised.
    • Patients may self-administer Emgality after appropriate training in subcutaneous injection technique.

    Rimegepant

    • Calcitonin gene-related peptide (CGRP) receptor antagonist.
    • Inhibits the function of CGRP, thereby preventing migraine attacks.
    • Administer 75 mg once daily for treatment of acute migraine.
    • Option to use on alternate days.
    • Side effects include common or very common nausea and hypersensitivity reactions.
    • Hypersensitivity reactions, including dyspnoea and rash, can occur days after administration.
    • Pregnancy is advised to avoid due to limited information available.
    • Breast feeding should be avoided due to the presence of gelatin in milk, which may be too small to be harmful.
    • In severe impairment, avoiding ergotism or renal impairment increases the risk of exposure.
    • Rimegepant oral lyophilisates should be placed on or under the tongue and allowed to dissolve.
    • Patients or their carers should be given advice on how to administer rimegepant oral lyophilisates.

    Ergotamine Tartrate

    • Medication used for managing cluster headaches.
    • Adults should take 1 mg once daily for 6 nights in 7.
    • Occasionally given for 1–2 weeks, dose to be taken at night.
    • Not licensed for the management of cluster headaches.
    • Contraindications include acute porphyrias, coronary heart disease, hyperthyroidism, inadequately controlled hypertension, obliterative vascular disease, peripheral vascular disease, Raynaud's syndrome, sepsis, severe hypertension, temporal arteritis, anemia, cardiac disease, dependence, elderly patients, and risk of peripheral vasospasm.
    • Side effects include common or very common abdominal pain, dizziness, nausea, vomiting, cyanosis, diarrhea, muscle weakness, pain in extremity, sensation abnormal, vasoconstriction, arrhythmias, cardiac valve fibrosis, dyspnoea, ergot poisoning, gangrene, intestinal ischaemia, myalgia, myocardial infarction, myocardial ischaemia, skin reactions, anxiety, arthralgia, blood disorder, cerebral ischaemia, confusion, constipation, depression, drowsiness, dry mouth, extrapyramidal symptoms, hallucination, renal artery spasm, seizure, sleep disorder, thrombosis, tremor, urinary retention, vision blurred.

    Triptans

    • Medication used for treating acute migraines.
    • Maximum dosage of 12.5 mg taken as soon as possible after onset.
    • Not licensed for use in the elderly.
    • Side effects include asthma, dizziness, drowsiness, nausea, vomiting, bone pain, chest pain, diarrhea, and dry mouth.

    5HT1-receptor Agonists

    • Used in treating various conditions such as dyspepsia, headache, myalgia, palpitations, paraesthesia, throat tightness, tinnitus, coronary vasospasm, myocardial infarction, tachycardia, intestinal ischaemia, seizure, and vision disorders.
    • Side effects include discontinuation if symptoms of heat, heaviness, pressure, or tightness occur.
    • Potential risks associated with using these medications during pregnancy, including breast feeding, hepatic impairment, renal impairment, and contraindications.
    • Manufacturer advises caution in mild to moderate impairment and avoids them in severe impairment.
    • Dosage for renal impairment can be adjusted to 12.5mg in 24 hours if creatinine clearance is less than 30 mL/minute.
    • Interactions with other medications, such as triptans, can cause common or very common side effects such as arrhythmias, asthenia, chest discomfort, chills, dizziness, drowsiness, dry mouth, feeling hot, flushing, gastrointestinal discomfort, headache, hyperhidrosis, increased risk of infection, muscle complaints, muscle tone increased, muscle weakness, nausea, pain, palpitations, sensation abnormal, throat tightness, vertigo, and more.
    • Contraindications during pregnancy include arrhythmias, coronary vasospasm, heart failure, ischaemic heart disease, peripheral vascular disease, previous cerebrovascular accident, previous myocardial infarction, transient ischaemic attack, Prinzmetal’s angina, severe hypertension, uncontrolled hypertension.
    • Potential side effects include common or very common adverse reactions such as agitation, appetite decreased, arthralgia, arthritis, confusion, depersonalization, depression, diarrhea, dyspnoea, ear pain, eye pain, insomnia, lacrimation disorder, malaise, mood altered, movement disorders, oedema, oral disorders, peripheral vascular disease, respiratory disorder, skin reactions, speech disorder, stupor, taste altered, thinking abnormal, thirst, tinnitus, tremor, urinary disorders, urinary tract disorder, vision disorders, yawning, rare or very rare asthma, breast pain, burping, conjunctivitis, constipation, gastrointestinal disorders, hyperbilirubinaemia, lymphadenopathy, menorrhagia, myopathy, shock, voice alteration, and frequency not known.

    Frovatriptan

    • Used for menstrual migraine prophylaxis.
    • Not licensed for use in the elderly.
    • May cause side effects such as asthma, chest discomfort, dizziness, drowsiness, dry mouth, flushing, gastrointestinal discomfort, headache, hyperhidrosis, nausea, sensation abnormal, throat complaints, vision disorders, anxiety, arrhythmias, arthralgia, concentration impaired, confusion, dehydration, depression, diarrhea, dysphagia, ear discomfort, eye discomfort, gastrointestinal disorders, hypertension, increased risk of infection, malaise, musculoskeletal stiffness, neuromuscular dysfunction, pain, palpitations, peripheral coldness, psychiatric disorders, skin reactions, sleep disorders, taste altered, temperature sensation, altered, thirst, tinnitus, tremor, urinary disorders, vertigo, rare or very rare breast tenderness, burping, constipation, ear disorder, epistaxis, fever, hiccups, hyperacusia, hypoglycaemia, irritable bowel syndrome, lymphadenopathy, memory loss, movement disorder, oesophageal spasm, oral disorders, piloerection, reflexes decreased, renal pain, respiratory disorders, self-mutilation, angioedema, coronary vasospasm, hypersensitivity, myocardial infarction, and side effects not known.

    Rizatriptan

    • Non-proprietary medication used for treating acute migraines.
    • Adults should take 10 mg as soon as possible after onset, followed by 10 mg after 2 hours if required.
    • Dose should be reduced to 5mg with concurrent use of propranolol.
    • Not licensed for use in the elderly.
    • Contra-indications include coronary vasospasm, ischaemic heart disease, peripheral vascular disease, previous cerebrovascular accident, previous myocardial infarction, previous transient ischaemic attack, Prinzmetal's angina, severe hypertension, and uncontrolled hypertension.
    • Factors that predispose to coronary artery disease include conditions such as coronary vasospasm, ischaemic heart disease, and elderly patients.
    • Side effects include decreased alertness, asthenia, diarrhea, dizziness, drowsiness, dry mouth, dyspepsia, feeling abnormal, headache, insomnia, musculoskeletal stiffness, nausea, pain, palpitations, sensation abnormal, throat complaints, vasodilation, vomiting, angioedema, arrhythmias, ataxia, disorientation, dyspnoea, face oedema, hyperhidrosis, hypertension, muscle weakness, myalgia, nervousness, skin reactions, syncope, taste altered, thirst, tongue swelling, tremor, vertigo, vision blurred, rare or very rare hypersensitivity, stroke, wheezing, frequency not known, colitis ischaemic, myocardial infarction, myocardial ischaemia, peripheral vascular disease, seizure, serotonin syndrome, and toxic epidermal necrosis.
    • Patients or carers should be given advice on how to administer rizatriptan orodispersible tablets and oral lyophilisates.
    • Drowsiness may affect performance of skilled tasks, such as driving.

    Sumatriptan

    • Medication used to treat acute migraines and acute cluster headaches.
    • Available in various dosages: 3 tablets for £13.37, 6 tablets for £32.80, and 12 tablets for £53.48.
    • Drug is also available as oral lyophilisate, which is sugar-free.
    • Treatment of acute migraines involves administering 50-100 mg for one dose, followed by 50-100 mg after at least 2 hours if required.
    • For intravenous injections, the dosage is 3-6 mg for 1 dose, followed by 3-6 mg after at least 1 hour if required. This dose should be taken only if migraine recurs.
    • For intravenous injections, the dosage is 10-20 mg, administered into one nostril, followed by 10-20 mg after at least 2 hours if required.
    • The maximum dosage is 40 mg per day.
    • Not licensed for use in the elderly.
    • Contra-indications include coronary vasospasm, ischaemic heart disease, mild uncontrolled hypertension, peripheral vascular disease, previous cerebrovascular accident, previous myocardial infarction, previous transient ischaemic attack, and Prinzmetal's angina.
    • Cautions for using Sumatriptan include conditions that predispose to coronary artery disease, the elderly, history of seizures, mild, controlled hypertension, and risk factors for seizures.
    • Side-effects include asthma, dizziness, drowsiness, dyspnoea, feeling abnormal, flushing, myalgia, nausea, pain, sensation abnormal, skin reactions, temperature, sensation altered, vomiting, rare or very rare hypersensitivity, and frequency not known.

    Zolmitriptan

    • Medication used to treat migraines.

    • Side effects: epistaxis, nasal irritation, taste altered, throat irritation, and haemorrhage or swelling.

    • Side effects should be discontinued if symptoms of heat, heaviness, pressure, or tightness occur.

    • Limited experience using it during pregnancy.

    • Manufacturers advise against using it unless the potential benefit outweighs the risk.

    • Breast feeding is present in milk but probably too small to be harmful; withhold breastfeeding for 12 hours after treatment.

    • Manufacturer advises caution for hepatic impairment and renal impairment.

    • Dose adjustments should be considered for oral use.### Zolmitriptan

    • Zolmitriptan is used to treat migraines and is available in various forms, including injection solutions and nasal sprays.

    • It can be sold to the public for treating previously diagnosed migraines, with a maximum daily dose of 100 mg.

    • The licensing of different medicines containing zolmitriptan can vary.

    • Dose adjustments are advised due to drug interactions, with a maximum dose of 5 mg in 24 hours when taken with certain medications that inhibit CYP1A2.

    • Zolmitriptan is not licensed for menstrual migraine prophylaxis, elderly use, or the treatment of cluster headaches.

    • It has contraindications such as arrhythmias, coronary vasospasm, ischemic heart disease, and uncontrolled hypertension.

    • Avoid use during pregnancy unless the potential benefit outweighs the risk.

    • Use with caution during breastfeeding as it is present in milk.

    • Zolmitriptan can cause side effects such as epistaxis, nasal irritation, and altered taste.

    Neuropathic Pain

    • Neuropathic pain results from damage to neural tissue and can be managed with tricyclic antidepressants, certain antiepileptic drugs, and opioids.
    • Topical local anesthetic preparations, such as lidocaine hydrochloride medicated plasters, can benefit patients with localized pain who cannot take oral medications.
    • Capsaicin is licensed for neuropathic pain, but the intense burning sensation during initial treatment may limit its use.
    • Capsaicin 0.075% cream is licensed for symptomatic relief of postherpetic neuralgia, and a self-adhesive patch containing capsaicin 8% is licensed for the treatment of peripheral neuropathic pain.
    • Corticosteroids can help relieve pressure in compression neuropathy and reduce pain.
    • Neuromodulation by spinal cord stimulation may benefit some patients.
    • Trigeminal neuralgia can be treated with carbamazepine, which reduces the frequency and severity of attacks.
    • Chronic facial pain may require prolonged use of analgesics or other drugs.
    • Patients on long-term therapy need to be monitored for progress and side effects.
    • Capsaicin is applied to the skin using cream or a patch, with the application being sparingly applied.

    Sleep Disorders

    • Insomnia is a common condition that can be treated with hypnotics and anxiolytics.
    • Benzodiazepines are the most commonly used anxiolytics and hypnotics, acting at benzodiazepine receptors associated with GABA.
    • Benzodiazepines are indicated for short-term relief of severe anxiety.
    • Withdrawal of benzodiazepines should be gradual to prevent withdrawal symptoms such as insomnia, anxiety, and tremors.
    • Short-acting hypnotics are preferred for patients with sleep onset insomnia, while long-acting hypnotics are indicated for patients with poor sleep maintenance.
    • Transient insomnia may occur due to extraneous factors such as noise and jet lag.
    • Short-term insomnia is usually related to an emotional problem or serious medical illness.
    • Chronic insomnia is rarely benefited by hypnotics and is sometimes due to mild dependence caused by injudicious prescribing.
    • In the elderly, benzodiazepines and Z-drugs should be avoided due to the risk of becoming ataxic and confused.
    • Zolpidem tartrate and zopiclone are nonbenzodiazepine hypnotics that act at the benzodiazepine receptor but are not licensed for long-term use.
    • Melatonin is licensed for short-term treatment of insomnia in adults over 55 years and for jet-lag in adults.

    Anxiety

    • Benzodiazepine anxiolytics can be effective in alleviating anxiety but should not be used as sole treatment for chronic anxiety or depression.
    • Beta-adrenoceptor blocking drugs reduce autonomic symptoms of anxiety, such as palpitation and tremor, but do not reduce non-autonomic symptoms.
    • Benzodiazepines are indicated for short-term relief of severe anxiety.
    • In panic disorders resistant to antidepressant therapy, benzodiazepines may be used as short-term adjuvant therapy.
    • Buspirone hydrochloride acts at specific serotonin (5HT1A) receptors and may take up to 2 weeks to respond to treatment.
    • Meprobamate is less effective than benzodiazepines, more hazardous in overdosage, and can also induce dependence.
    • Barbiturates are intermediate-acting drugs used for treating severe insomnia in patients already taking barbiturates.
    • Benzodiazepines are present in milk and should be avoided if possible during breastfeeding.

    Flurazepam

    • Flurazepam is a medication used to treat insomnia.
    • Adults should take 15-30 mg once daily, with elderly doses recommended for debilitated patients.
    • Paradoxical effects of flurazepam include talkativeness, excitement, and increased anxiety.
    • Flurazepam capsules are not prescribable in NHS primary care.

    Lormetazepam

    • Lormetazepam is used for short-term insomnia and has contraindications such as chronic psychosis and respiratory depression.
    • Paradoxical effects of lormetazepam include increased hostility and aggression, talkativeness, and excitement.
    • Adults should take 10-20 mg once daily, with higher doses only given in exceptional circumstances.
    • For elderly patients, 10 mg once daily or 20 mg once daily is advised.

    Temazepam

    • Temazepam is a medication used for treating sleep disorders, anxiety, and other conditions.
    • It is not licensed for conscious sedation for dental procedures and has contraindications such as chronic psychosis and respiratory depression.
    • Paradoxical effects include increased hostility and aggression, anxiety, and perceptual disorders.
    • Benzodiazepines are present in milk and should be avoided during breastfeeding.
    • Dose adjustments should be initiated at 5mg once daily, increasing to 10 mg or 20mg once daily in extreme cases.

    Clomethiazole

    • Clomethiazole is a medication used to treat insomnia.
    • It should be administered with dilute liquid and plenty of water or juice to mask the unpleasant taste.
    • Drowsiness may persist the next day and affect skilled tasks, such as driving.
    • Alcohol-induced effects may be enhanced.

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