Misuse of Drugs Regulations Quiz
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Questions and Answers

Which of the following drugs is classified as a Class A substance?

  • Cannabis
  • Methadone hydrochloride (correct)
  • Dihydrocodeine tartrate
  • Barbiturates

    • What is primarily required for the production, possession, or supply of drugs classified under Schedule 1?

  • A National Health Service certification
  • A Home Office license (correct)
  • A prescription from a registered medical professional
  • Insurance coverage

    • Which of the following substances is included in Class C drugs?

  • Zolpidem tartrate (correct)
  • Diamorphine hydrochloride
  • Cocaine
  • Alfentanil

    • Which Schedule includes major stimulants and cannabis-based products for medicinal use?

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

    What is a significant requirement when handling Schedule 1 Controlled Drugs?

    <p>Use a Controlled Drug register for record-keeping</p> Signup and view all the answers

    Which drug is NOT classified under Class B?

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

    What aspect of the Misuse of Drugs Regulations 2001 is NOT addressed by the five schedules?

    <p>Harmful effects of drugs</p> Signup and view all the answers

    Which of these is an example of a Class C substance?

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

    What is required for a medical practitioner to prescribe diamorphine hydrochloride for drug addiction treatment?

    <p>They must hold a special license issued by the Home Secretary.</p> Signup and view all the answers

    What is the primary aim of treatment for dementia?

    <p>To promote independence and maintain function.</p> Signup and view all the answers

    Which of the following symptoms may persist in chronic cannabis users?

    <p>Paranoid symptoms.</p> Signup and view all the answers

    Which drug is considered first-line treatment for mild-to-moderate Alzheimer's disease?

    <p>Donepezil hydrochloride.</p> Signup and view all the answers

    What is a common side effect of Donepezil?

    <p>Dizziness.</p> Signup and view all the answers

    What is the drug of choice for patients with severe Alzheimer's disease?

    <p>Memantine hydrochloride.</p> Signup and view all the answers

    In patients with vascular dementia, when should acetylcholinesterase inhibitors be considered?

    <p>If they exhibit suspected co-morbid Alzheimer's disease.</p> Signup and view all the answers

    Which of the following non-drug interventions is suggested for managing sleep problems in dementia patients?

    <p>Sleep hygiene education.</p> Signup and view all the answers

    What is the recommended action if a medical practitioner deviates from the intended method of supply for a patient?

    <p>Documentation should be completed.</p> Signup and view all the answers

    What condition can cannabis use exacerbate?

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

    For patients with severe dementia with Lewy bodies, which medication is appropriate?

    <p>Galantamine.</p> Signup and view all the answers

    What is the Misuse of Drugs (Notification of and Supply to Addicts) (Northern Ireland) Regulations 1973 concerned with?

    <p>Sending particulars of addicted persons to authorities.</p> Signup and view all the answers

    Which of the following should be regularly reviewed when prescribing antipsychotic drugs to dementia patients?

    <p>Dosages and duration of treatment.</p> Signup and view all the answers

    What type of therapy should be considered for patients with mild-to-moderate dementia who have depression or anxiety?

    <p>Counseling and relaxation therapies.</p> Signup and view all the answers

    Which statement about Schedule 4 Controlled Drugs is accurate?

    <p>Prescription requirements do not apply to these drugs.</p> Signup and view all the answers

    What is a requirement for prescriptions of Schedule 5 Controlled Drugs?

    <p>They are exempt from most Controlled Drug requirements.</p> Signup and view all the answers

    What must a prescription for a Controlled Drug always include?

    <p>The total quantity specified in both figures and words.</p> Signup and view all the answers

    Prescriptions for Schedule 2 and 3 Controlled Drugs can be amended under which condition?

    <p>If the total quantity is specified only in words or contains minor errors.</p> Signup and view all the answers

    What is the maximum period for which prescriptions for Schedule 2, 3, and 4 Controlled Drugs can generally be issued?

    <p>30 days.</p> Signup and view all the answers

    What is the validity period for a prescription for a Controlled Drug in Schedule 2 or 3?

    <p>28 days from the date stated.</p> Signup and view all the answers

    What is true regarding repeatable prescriptions?

    <p>They are only allowed for Schedule 4 and 5 Controlled Drugs.</p> Signup and view all the answers

    Which advice is recommended to prevent misuse of prescription forms?

    <p>Never pre-sign prescription forms.</p> Signup and view all the answers

    What type of signature is acceptable on a machine-written prescription for Controlled Drugs?

    <p>Handwritten signature must be included.</p> Signup and view all the answers

    For which drugs should prescribers be particularly vigilant to avoid supply problems?

    <p>Drugs associated with dependence and withdrawal symptoms.</p> Signup and view all the answers

    What is the proper course of action if a prescription is lost or suspected to be stolen?

    <p>Contact local authorities immediately.</p> Signup and view all the answers

    What must be included in a management plan for drugs associated with dependence?

    <p>Intended outcomes, dose, titration, and risks.</p> Signup and view all the answers

    Which of the following is a characteristic of prescriptions for Schedule 5 drugs?

    <p>They must be retained for invoice records only.</p> Signup and view all the answers

    Which of the following drugs is commonly associated with addiction?

    <p>Diamorphine hydrochloride.</p> Signup and view all the answers

    What adjustments should be made for patients with mild to moderate hepatic impairment when administering Donepezil?

    <p>Dose adjustments should be based on individual tolerability.</p> Signup and view all the answers

    What is the initial recommended dosing for adults starting acetylcholinesterase inhibitor therapy?

    <p>4 mg twice daily for 4 weeks.</p> Signup and view all the answers

    What is a major caution when prescribing acetylcholinesterase inhibitors to elderly patients?

    <p>Higher risk of adverse effects and inappropriate prescriptions.</p> Signup and view all the answers

    Which of the following medications is NOT part of the national funding/access decisions for Alzheimer's disease treatment?

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

    What is a common side effect associated with anticholinesterase medications?

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

    How should patients be advised regarding symptoms of serious skin reactions when using Donepezil?

    <p>Seek medical advice if symptoms occur.</p> Signup and view all the answers

    Which dosage form of rivastigmine is recommended for patients unable to take oral medications?

    <p>Transdermal patches.</p> Signup and view all the answers

    What is the maximum recommended dosage for Memantine hydrochloride?

    <p>20 mg daily</p> Signup and view all the answers

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

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

    Which factor does NOT warrant caution when prescribing acetylcholinesterase inhibitors?

    <p>Previous cardiac surgeries.</p> Signup and view all the answers

    Which factor is NOT directly considered when choosing an antiepileptic drug?

    <p>Patient's income level</p> Signup and view all the answers

    What is the recommended daily maintenance dose for modified-release acetylcholinesterase medications?

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

    What should be done if the oral acetylcholinesterase treatment is interrupted for several days?

    <p>Reduce the dose before resuming.</p> Signup and view all the answers

    For which condition is Memantine primarily recommended?

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

    When adjusting the dose of Memantine, what eGFR range requires reducing the dose to 10 mg daily?

    <p>5–29 mL/min/1.73m²</p> Signup and view all the answers

    Which medication form is commonly used in the treatment of Alzheimer's disease?

    <p>Transdermal patches.</p> Signup and view all the answers

    What is the initial dose of rivastigmine in oral form for treating Alzheimer’s dementia?

    <p>1.5 mg twice daily.</p> Signup and view all the answers

    Which of these administrations for Rivastigmine is least likely to cause side effects?

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

    What is a potential consequence of incorrect administration of transdermal patches of rivastigmine?

    <p>Risk of fatal overdose.</p> Signup and view all the answers

    What is the purpose of starting antiepileptic drug doses low and increasing them gradually?

    <p>To avoid significant adverse effects</p> Signup and view all the answers

    Whose decisions directly recommend the use of Donepezil for Alzheimer's treatment?

    <p>NICE decisions.</p> Signup and view all the answers

    What is the possible consequence of combination therapy with antiepileptic drugs?

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

    Which specific side effect of Rivastigmine can lead to cardiovascular complications?

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

    What should patients do before applying a new Rivastigmine transdermal patch?

    <p>Remove the previous day's patch</p> Signup and view all the answers

    What dosage adjustments should be made for Memantine if eGFR is less than 5 mL/min/1.73m²?

    <p>Reduce to 10 mg daily</p> Signup and view all the answers

    Which side effect is unique to Rivastigmine when compared to traditional antiepileptic medications?

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

    Which antiepileptic approach is taken if monotherapy with a first-line drug fails?

    <p>Try a monotherapy with an alternative drug</p> Signup and view all the answers

    What is the maximum daily dosage recommended for bipolar disorder unresponsive to lithium?

    <p>1.6 g</p> Signup and view all the answers

    What initial dose is recommended for treating trigeminal neuralgia in adults?

    <p>100-200 mg</p> Signup and view all the answers

    What is the common side effect of carbamazepine that involves sensory perception?

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

    What is the daily maintenance dosage range for children aged 5-11 years on carbamazepine?

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

    What should be monitored to ensure the safe use of carbamazepine?

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

    In which condition is carbamazepine NOT licensed for use?

    <p>Diabetic neuropathy</p> Signup and view all the answers

    What is the gradual increase in dosage recommended for focal and generalized tonic-clonic seizures in adults?

    <p>0.8-1.2 g daily</p> Signup and view all the answers

    What should be done if combination therapy fails to reduce seizures?

    <p>Revert to the previous regimen that balanced efficacy and tolerability.</p> Signup and view all the answers

    Which of the following is a recommended course of action for a patient experiencing mood changes and distressing thoughts on antiepileptic drugs?

    <p>Seek medical advice and possibly refer for appropriate treatment.</p> Signup and view all the answers

    What serious condition should lead to immediate withdrawal of carbamazepine?

    <p>Acute liver disease</p> Signup and view all the answers

    What condition might exacerbate seizures in patients taking carbamazepine?

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

    What is the time frame for the onset of antiepileptic hypersensitivity syndrome after exposure?

    <p>Between 1 and 8 weeks.</p> Signup and view all the answers

    If a patient wishes to withdraw from antiepileptic medication after being seizure-free for two years, what is the recommended approach?

    <p>Gradually reduce the dosage of one drug at a time.</p> Signup and view all the answers

    How should the initial dose of carbamazepine be adjusted for elderly patients?

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

    What initial daily dosage of carbamazepine is recommended for children aged 12-17 years?

    <p>100-200 mg</p> Signup and view all the answers

    What must patients do if they experience a seizure while driving?

    <p>Stop driving and inform the Driver and Vehicle Licensing Agency (DVLA).</p> Signup and view all the answers

    Which antiepileptic drug is known to be highly teratogenic, especially in females of childbearing potential?

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

    What is a potential serious adverse reaction associated with the presence of the HLA-B*1502 allele?

    <p>Stevens-Johnson syndrome</p> Signup and view all the answers

    What important supplementation is advised for patients taking carbamazepine who have inadequate sun exposure?

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

    What should a healthcare professional consider when maintaining a patient's supply of antiepileptic medications?

    <p>Continuity of supply of a specific manufacturer's product.</p> Signup and view all the answers

    What is the maximum period a patient may drive after having a seizure while asleep?

    <p>One year.</p> Signup and view all the answers

    What phenomenon can occur due to interactions with carbamazepine?

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

    During a safety review, which drugs were determined to be safer in pregnancy with no increased risk of major congenital malformations?

    <p>Lamotrigine and Levetiracetam.</p> Signup and view all the answers

    What is a common characteristic of the medications listed as having dose-dependent risks during pregnancy?

    <p>They are associated with increased major congenital malformation risk.</p> Signup and view all the answers

    What should be done if signs of antiepileptic hypersensitivity syndrome develop?

    <p>Withdraw the drug immediately and seek expert advice.</p> Signup and view all the answers

    What is a crucial factor to consider when assessing a patient's readiness to stop antiepileptic medication?

    <p>Risk of seizure recurrence.</p> Signup and view all the answers

    How should dosage reduction of benzodiazepines and barbiturates typically be managed?

    <p>Gradually reduced over a longer period than other drugs.</p> Signup and view all the answers

    What non-clinical factors must be taken into account when prescribing antiepileptic drugs?

    <p>Co-morbid conditions such as autism or mental health issues.</p> Signup and view all the answers

    Which antiepileptic drug is associated with an increased risk of intra-uterine growth restriction during pregnancy?

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

    What should be closely monitored in infants breastfed by mothers taking combination therapy of antiepileptic drugs?

    <p>Sedation and feeding difficulties</p> Signup and view all the answers

    In the treatment of focal seizures, which medication is NOT indicated as a first-line option?

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

    For the treatment of absence seizures, which is considered first-line therapy?

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

    Which drug is NOT recommended for myoclonic seizures due to the potential to exacerbate them?

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

    Sodium valproate is NOT typically used first-line in which patient population?

    <p>Pregnant women</p> Signup and view all the answers

    What should be considered when treating Dravet syndrome if sodium valproate is unsuccessful?

    <p>Triple therapy with clobazam and stiripentol</p> Signup and view all the answers

    Which of the following is true about atonic or tonic seizures?

    <p>They are typically associated with childhood epilepsy syndromes.</p> Signup and view all the answers

    What is recommended for the management of convulsive status epilepticus if no emergency plan is available?

    <p>Administration of a benzodiazepine</p> Signup and view all the answers

    What is crucial for monitoring in infants whose mothers are taking phenobarbital?

    <p>Developmental milestones</p> Signup and view all the answers

    When should a patient with an epilepsy syndrome likely to be drug-resistant be referred to a specialized service?

    <p>At diagnosis, regardless of treatment history</p> Signup and view all the answers

    Which of the following statements regarding breast-feeding for mothers on antiepileptic monotherapy is accurate?

    <p>It is generally encouraged.</p> Signup and view all the answers

    Which statement best describes the treatment for myoclonic seizures in females who are able to have children?

    <p>Levetiracetam should be offered as first-line monotherapy.</p> Signup and view all the answers

    Which drug may cause drowsiness in breastfed infants and requires caution when taken by nursing mothers?

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

    What is the primary reason to use paraenteral thiamine in seizure management?

    <p>When alcohol abuse is suspected</p> Signup and view all the answers

    Under what circumstances should second-line treatment options be initiated?

    <p>If the seizure has not stopped after 5-10 minutes of the first dose of benzodiazepine</p> Signup and view all the answers

    What condition requires specific treatment for prolonged or recurrent episodes?

    <p>Febrile convulsions</p> Signup and view all the answers

    What is the recommended administration method for cannabidiol?

    <p>Via nasogastric or gastrostomy tube</p> Signup and view all the answers

    Which situation would indicate the use of general anesthesia in seizure treatment?

    <p>The patient has a complete lack of awareness</p> Signup and view all the answers

    What should be monitored in patients taking cannabidiol?

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

    What is advised regarding pregnancy while taking antiepileptic drugs?

    <p>Avoid unless benefits outweigh risks</p> Signup and view all the answers

    What should be done if a patient misses a dose of their antiepileptic medication?

    <p>Take the missed dose as soon as remembered</p> Signup and view all the answers

    How should the initial dose of Briviact be managed for adults?

    <p>Begin with 100-200 mg once a day</p> Signup and view all the answers

    What is a common side effect of antiepileptic drugs?

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

    When converting from oral to intravenous antiepileptic therapy, what is essential to maintain?

    <p>The total daily dose</p> Signup and view all the answers

    What should be done for elderly patients starting antiepileptic medication?

    <p>Initial doses should be reduced</p> Signup and view all the answers

    What is the maximum dose of cannabidiol recommended for adults?

    <p>2.5 mg/kg twice daily</p> Signup and view all the answers

    For what purpose is reflexum indicated in seizure management?

    <p>Short-term use when oral therapy is not possible</p> Signup and view all the answers

    What is recommended regarding pre-treatment screening for the HLA-B* 1502 allele in individuals of Han Chinese or Thai origin?

    <p>It should be avoided unless essential.</p> Signup and view all the answers

    What is the recommended dilution for intermittent intravenous infusion of Pro-Epanutin®?

    <p>Dilute to a concentration of 1.5-25 mg/mL.</p> Signup and view all the answers

    Which dosage form is not allowed for gabapentin use in children under 12 years old?

    <p>Capsules.</p> Signup and view all the answers

    What is the initial recommended dosage of gabapentin for children aged 6-11 years?

    <p>10 mg/kg once daily.</p> Signup and view all the answers

    What could potentially increase the risk of severe respiratory depression in patients taking gabapentin?

    <p>Compromised respiratory function.</p> Signup and view all the answers

    In what context should healthcare professionals observe patients for signs of gabapentin abuse?

    <p>Before prescribing gabapentin and during treatment.</p> Signup and view all the answers

    Which of the following contraindications is associated with gabapentin?

    <p>CNS depressant use.</p> Signup and view all the answers

    For adults, the recommended dosage regimen for gabapentin starts with what initial dose?

    <p>300 mg once daily.</p> Signup and view all the answers

    What risk is associated with gabapentin in relation to seizures?

    <p>It may exacerbate seizures in certain patients.</p> Signup and view all the answers

    In what form does gabapentin exist as a non-proprietary option?

    <p>Tablets and oral solutions.</p> Signup and view all the answers

    Which of the following adverse reactions may occur with gabapentin?

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

    What serious concern should patients be informed about regarding gabapentin?

    <p>It may interact dangerously with alcohol.</p> Signup and view all the answers

    Which component in gabapentin oral solution may exceed WHO daily intake limits for low body weight adolescents or adults?

    <p>Propylene glycol, acesulfame K, and saccharin sodium.</p> Signup and view all the answers

    What should be monitored in patients taking gabapentin?

    <p>Signs of gabapentin abuse.</p> Signup and view all the answers

    What should practitioners monitor when a patient is treated with carbamazepine?

    <p>Plasma concentration, blood counts, and hepatic/renal function</p> Signup and view all the answers

    What is the recommended approach for discontinuing treatment with carbamazepine for bipolar disorder?

    <p>Gradual reduction over at least 4 weeks</p> Signup and view all the answers

    In which population is pre-treatment screening for the HLA-B*1502 allele particularly advised?

    <p>Individuals of Han Chinese or Thai origin</p> Signup and view all the answers

    What side effect is NOT commonly associated with cenobamate?

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

    What is a significant caution when prescribing eslicarbazepine for patients?

    <p>Risk of severe electrolyte imbalance and cardiac issues</p> Signup and view all the answers

    What is the typical target dose for cenobamate after initial titration?

    <p>200 mg once daily</p> Signup and view all the answers

    What should be done if a patient exhibits symptoms of drug reaction with eosinophilia and systemic symptoms (DRESS)?

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

    What advice should be given regarding driving while on treatment with drugs like cenobamate or eslicarbazepine?

    <p>Caution due to increased risk of somnolence and dizziness</p> Signup and view all the answers

    What should a patient of childbearing potential consider when taking cenobamate?

    <p>Contraception should be used during and for 4 weeks after treatment</p> Signup and view all the answers

    What is recommended for patients at risk of hyponatraemia when taking eslicarbazepine?

    <p>Regular monitoring of plasma-sodium concentration</p> Signup and view all the answers

    Which contraindication must be considered before starting eslicarbazepine?

    <p>Second- or third-degree AV block</p> Signup and view all the answers

    How is eslicarbazepine typically started in adults and elderly patients?

    <p>With 400 mg once daily for 1–2 weeks</p> Signup and view all the answers

    What should be done if a patient develops signs of hepatic impairment during treatment?

    <p>Consider discontinuing treatment and monitoring function</p> Signup and view all the answers

    What is the maximum dose for gabapentin when used for monotherapy in children weighing 50 kg and above?

    <p>300 mg twice daily</p> Signup and view all the answers

    What dosage adjustment is recommended for adults with a creatinine clearance of 30-49 mL/minute?

    <p>300-900 mg daily in three divided doses</p> Signup and view all the answers

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

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

    What is the starting dose of gabapentin for children aged 2-17 years weighing 10-39 kg?

    <p>1 mg/kg twice daily</p> Signup and view all the answers

    In the adjunctive treatment of primary generalized tonic-clonic seizures, what is the maximum daily dose of gabapentin?

    <p>200 mg twice daily</p> Signup and view all the answers

    For which condition may gabapentin exacerbate seizures?

    <p>Both A and B</p> Signup and view all the answers

    What is the recommended initial dosage of lacosamide for treating epilepsy in adults?

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

    Which medication should be avoided for patients with second- or third-degree AV block?

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

    What dosage adjustment should be made for a child aged 2-17 years weighing between 40-49 kg after one week of treatment?

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

    What is one potential risk associated with the use of gabapentin during pregnancy?

    <p>Neurological disorders in the infant</p> Signup and view all the answers

    What monitoring measure is essential when a patient is undergoing treatment with gabapentin?

    <p>Screening for signs of abuse</p> Signup and view all the answers

    What is the maximum dose for children between 2-17 years weighing 10-39 kg when taking gabapentin?

    <p>6 mg/kg twice daily</p> Signup and view all the answers

    What is a common misconception about the forms of gabapentin available?

    <p>It has various forms available from special-order manufacturers.</p> Signup and view all the answers

    What is a common side effect reported with gabapentin?

    <p>Behavioral abnormalities</p> Signup and view all the answers

    What is the maximum daily dosage of lamotrigine for children aged 12-17 years weighing 50 kg and above?

    <p>1.5 g twice daily</p> Signup and view all the answers

    What factor is associated with an increased risk of serious skin reactions when using lamotrigine?

    <p>Concomitant use of valproate</p> Signup and view all the answers

    Which of the following conditions can lamotrigine exacerbate?

    <p>Myoclonic seizures</p> Signup and view all the answers

    What is the recommended initial daily dose for children aged 1-5 months being treated with lamotrigine?

    <p>7 mg/kg once daily</p> Signup and view all the answers

    Which side effect is more common in patients with a prior history of rash from other antiepileptic drugs?

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

    What is a common side effect of lacosamide?

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

    What should be done if a patient experiences a rash while on lamotrigine?

    <p>Consider withdrawal from lamotrigine</p> Signup and view all the answers

    When adjusting doses of lamotrigine, how often should the dose generally be increased?

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

    Which patient group is advised against the use of lacosamide due to potential risks?

    <p>Women who are pregnant</p> Signup and view all the answers

    For which condition is the intravenous administration of lamotrigine specifically recommended?

    <p>Convulsive status epilepticus</p> Signup and view all the answers

    Which condition should patients be counseled about regarding lacosamide treatment?

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

    Which medication requires careful monitoring for plasma-drug concentration during pregnancy?

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

    What is the recommended maintenance dosage range for adults taking lacosamide?

    <p>100-200 mg daily</p> Signup and view all the answers

    What is the consequence of missing a dose of lacosamide for more than 6 hours?

    <p>Skip the missed dose and continue as normal</p> Signup and view all the answers

    What form of lamotrigine should be used for children under 6 years or those weighing less than 25 kg?

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

    What condition is lamotrigine NOT indicated for?

    <p>Parkinson’s disease</p> Signup and view all the answers

    How should lacosamide be administered via intravenous infusion for doses greater than 200 mg?

    <p>Give over at least 30 minutes</p> Signup and view all the answers

    What is the initial dosing recommendation for children aged 12-17 taking lacosamide for epilepsy?

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

    Which symptom may develop as a serious adverse effect of lamotrigine?

    <p>Haemophagocytic lymphohistiocytosis</p> Signup and view all the answers

    For patients on lamotrigine, what should patients and caregivers be vigilant for?

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

    Which of the following is NOT a recommended dosage adjustment for patients restarting lacosamide after more than 5 days?

    <p>Increase dosage immediately by 50 mg</p> Signup and view all the answers

    What potential serious reaction should patients be aware of when using lacosamide?

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

    Which of the following is a common side effect of lamotrigine?

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

    Which of the following formulations of lacosamide may contain sodium?

    <p>Infusion vials</p> Signup and view all the answers

    What is the maximum daily dosage for children 2-11 years old taking lacosamide?

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

    What should be monitored when a patient is treated with lacosamide?

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

    Which best describes the appropriate use of lacosamide in pediatric patients?

    <p>As adjunctive therapy for partial-onset seizures</p> Signup and view all the answers

    How is lacosamide's effectiveness assessed in seizure management?

    <p>By reduction in the frequency of seizures</p> Signup and view all the answers

    What is the initial recommended dosage of ethosuximide for children aged 1-5 years?

    <p>5 mg/kg twice daily</p> Signup and view all the answers

    What is a notable risk factor for the use of ethosuximide during treatment?

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

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

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

    What should be monitored if a patient on ethosuximide exhibits symptoms like fever and mouth ulcers?

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

    What is the common dosage adjustment for adults taking ethosuximide after initial treatment?

    <p>Increased in steps of 250 mg every 5-7 days</p> Signup and view all the answers

    Fosphenytoin sodium is primarily used for treating seizures associated with what condition?

    <p>Neurosurgery or head injury</p> Signup and view all the answers

    What type of monitoring is required for patients starting on fenfluramine?

    <p>Echocardiogram every 6 months</p> Signup and view all the answers

    What is a common side effect of fenfluramine?

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

    Which statement regarding the dosage of ethosuximide for children aged 6-17 years is correct?

    <p>The initial dosage is 250 mg twice daily.</p> Signup and view all the answers

    What potential effect does ethosuximide have on appetite?

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

    What is advised if hypotension occurs while administering phenytoin?

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

    Which of the following is a contraindication for fenfluramine use?

    <p>Pulmonary arterial hypertension</p> Signup and view all the answers

    What should patients be informed to recognize when taking ethosuximide?

    <p>Symptoms of blood disorders</p> Signup and view all the answers

    What is the initial recommended dosage for adults beginning treatment with ethosuximide?

    <p>500 mg daily in two divided doses</p> Signup and view all the answers

    Which of the following strains on the body can ethosuximide cause?

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

    What is the maximum daily dosage for children aged 4-11 years with a body weight of 30 kg and above for focal seizures?

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

    Which age group is prescribed a starting dose of 2 mg taken before bedtime for focal seizures?

    <p>Children aged 12-17 years</p> Signup and view all the answers

    How often can the dosage be increased for children aged 4-11 years, with a weight of 20-29 kg?

    <p>At least every two weeks</p> Signup and view all the answers

    For which condition is the intravenous loading dose for children aged 1 month-11 years set at 20 mg/kg?

    <p>Status epilepticus</p> Signup and view all the answers

    What daily dose should be avoided in patients with moderate to severe impairment while using Perampanel?

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

    Which form of medication is NOT mentioned as available for the adjunctive treatment of seizures?

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

    What is a common side effect of antiepileptic drugs listed?

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

    How should the dosage for adjunctive treatment of primary generalized tonic-clonic seizures be adjusted?

    <p>Based on plasma-phenytoin concentration</p> Signup and view all the answers

    What is the recommended increase in dosage for children ages 7-11 years if the initial dose is tolerated?

    <p>1 mg every 2 weeks</p> Signup and view all the answers

    What must be monitored when changing formulations of phenytoin medications?

    <p>Plasma-phenytoin concentration</p> Signup and view all the answers

    What is the recommended initial dosing for children aged 6-17 years starting monotherapy for focal seizures?

    <p>4-5 mg/kg twice daily</p> Signup and view all the answers

    Which condition is not licensed for treatment with oxcarbazepine?

    <p>Primary generalised tonic-clonic seizures</p> Signup and view all the answers

    What is the maximum daily dose of levetiracetam indicated for a patient with an eGFR of 35 mL/minute/1.73m2?

    <p>1.5 g</p> Signup and view all the answers

    Which of the following statements is true regarding switching between oral and intravenous levetiracetam therapy?

    <p>The intravenous dose should be the same as the established oral dose.</p> Signup and view all the answers

    What adverse reaction should patients and caregivers seek immediate medical advice for while taking levetiracetam?

    <p>Signs of depression or suicidal ideation</p> Signup and view all the answers

    In which specific population is pre-treatment screening for HLA-B*1502 allele particularly emphasized?

    <p>Individuals of Han Chinese or Thai origin</p> Signup and view all the answers

    What is a common monitoring requirement for patients on oxcarbazepine?

    <p>Monitor plasma-sodium concentration</p> Signup and view all the answers

    What should be done if a patient with renal impairment has a creatinine clearance of less than 30 mL/minute?

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

    Which of the following side effects is associated with oxcarbazepine use?

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

    What is a significant caution associated with carbamazepine and its related drugs such as oxcarbazepine?

    <p>Increased risk of Stevens-Johnson syndrome</p> Signup and view all the answers

    What is the concentration available for infusion solutions of levetiracetam?

    <p>100 mg per 1 ml</p> Signup and view all the answers

    What kind of dosing adjustment may be needed when using high doses of oxcarbazepine?

    <p>Reducing doses of concomitant antiepileptics</p> Signup and view all the answers

    Which of the following symptoms indicates a need for immediate medical attention while taking antiepileptic medications?

    <p>Lethargy and confusion</p> Signup and view all the answers

    What is the effect of levetiracetam on driving and performing skilled tasks?

    <p>Increased risk of somnolence and CNS side effects</p> Signup and view all the answers

    What is a significant risk associated with the use of injectable phenytoin?

    <p>Medication errors during the administration process</p> Signup and view all the answers

    Which condition is NOT a contraindication for injectable phenytoin?

    <p>Seizures associated with absence epilepsy</p> Signup and view all the answers

    What constitutes a potential complication when phenytoin is administered?

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

    Which of the following side effects is linked with phenytoin toxicity?

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

    What is one of the key reasons for recommending monitoring plasma-drug concentration in patients using phenytoin?

    <p>To accurately adjust dosages due to the narrow therapeutic index</p> Signup and view all the answers

    Which of the following interactions is associated with phenytoin?

    <p>Granulocytosis and bone fractures</p> Signup and view all the answers

    In patients with the HLA-B*1502 allele, what risk is significantly increased?

    <p>Risk of Stevens-Johnson syndrome</p> Signup and view all the answers

    What adverse effect may occur with the use of phenytoin in pregnant women?

    <p>Major congenital malformations</p> Signup and view all the answers

    What is the maximum dose for Pregabalin in children aged 4-17 years weighing between 30-50 kg?

    <p>900 mg twice daily</p> Signup and view all the answers

    Which side effect is NOT commonly associated with antiepileptic medications?

    <p>Hair growth stimulation</p> Signup and view all the answers

    What is advised regarding the use of rufinamide during breastfeeding?

    <p>It should be avoided unless essential</p> Signup and view all the answers

    In the treatment of seizures associated with Lennox-Gastaut syndrome, who is responsible for initiating therapy without valproate?

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

    What is a significant caution when switching between different manufacturers' products for treating epilepsy?

    <p>Potential for cross-sensitivity reactions</p> Signup and view all the answers

    What is the dosing adjustment interval for increasing the dose of pregabalin in children?

    <p>3 days</p> Signup and view all the answers

    Which of these drugs requires careful consideration about its effects on driving and skilled tasks?

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

    What is a common psychiatric side effect associated with antiepileptic drugs?

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

    What specific effect does rufinamide have according to the updated guidelines?

    <p>Causes significant toxicity in animal studies</p> Signup and view all the answers

    What type of syndrome should patients be counseled about when using antiepileptic drugs?

    <p>Antiepileptic hypersensitivity syndrome</p> Signup and view all the answers

    Which of the following side effects is associated with both Pregabalin and other antiepileptic drugs?

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

    What is a prescribing requirement for Pregabalin in children under 18?

    <p>It is not recommended for use</p> Signup and view all the answers

    What is the appropriate method for administering rufinamide according to the guidelines?

    <p>Crushed and dissolved in water</p> Signup and view all the answers

    What is a common renal effect associated with the use of antiepileptics?

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

    What should be monitored prior to initiating treatment with sodium valproate?

    <p>Hepatic and renal function</p> Signup and view all the answers

    What is the recommended approach when discontinuing treatment with sodium valproate?

    <p>Gradually reduce the dose over at least 4 weeks</p> Signup and view all the answers

    Which formulation of sodium valproate can be mixed with soft food or drink?

    <p>Episenta capsules</p> Signup and view all the answers

    What is the maximum daily dose of Tiagabine for adults?

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

    What must be ensured for female patients prescribed sodium valproate?

    <p>Possession of a patient card</p> Signup and view all the answers

    Which medication can be prescribed alongside Tiagabine for treating seizures?

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

    What potential side effect is associated with stiripentol?

    <p>Suicidal behaviors</p> Signup and view all the answers

    What type of test should be conducted every six months for patients on sodium valproate?

    <p>Blood count and liver function tests</p> Signup and view all the answers

    How should sodium valproate intravenous injection be prepared?

    <p>Diluted with glucose 5% or sodium chloride 0.9%</p> Signup and view all the answers

    What is a notable consideration when switching oral formulations of treatment for epilepsy?

    <p>Seizure frequency and treatment history</p> Signup and view all the answers

    What is the initial dosage recommendation for children aged 12-17 years using Tiagabine?

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

    What is the price range for Epival CR gastro-resistant tablets?

    <p>£3.50 to £8.73</p> Signup and view all the answers

    Which action should patients or caregivers take regarding symptoms of blood disorders?

    <p>Seek immediate medical attention if symptoms develop</p> Signup and view all the answers

    What is the recommended trough plasma-phenytoin concentration range for neonates?

    <p>6-15 mg/litre</p> Signup and view all the answers

    For intravenous use of phenytoin in adults, what is the maximum recommended rate of administration?

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

    What condition can compromise the binding of phenytoin in the body leading to potential toxicity?

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

    What is the advised administration rate for phenytoin in children when given intravenously?

    <p>1 mg/kg/minute</p> Signup and view all the answers

    What potential risk is associated with the use of pregabalin during the first trimester of pregnancy?

    <p>Increased risk of major congenital malformations</p> Signup and view all the answers

    Which of the following statements about the administration of phenytoin is incorrect?

    <p>Phenytoin can be infused rapidly without precautions.</p> Signup and view all the answers

    What should healthcare professionals monitor in patients receiving pregabalin?

    <p>Signs of abuse and dependence</p> Signup and view all the answers

    What is the usual total plasma-phenytoin concentration for optimum response in adults?

    <p>10-20 mg/litre</p> Signup and view all the answers

    What is an unlicensed indication for the use of clonazepam?

    <p>Panic disorders resistant to antidepressants</p> Signup and view all the answers

    Which population should exercise caution due to an increased risk of respiratory depression with pregabalin?

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

    What is a significant symptom that would require immediate medical attention when taking phenytoin?

    <p>Mouth ulcers</p> Signup and view all the answers

    Which monitoring practice is typically not justified for children on antiepileptic drugs?

    <p>Routine measurement of plasma concentrations</p> Signup and view all the answers

    What is a potential side effect of clonazepam that affects physical abilities?

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

    What therapeutic range is recommended for plasma-phenytoin concentration in children?

    <p>10-20 mg/litre</p> Signup and view all the answers

    What should patients be educated about regarding the potential risks when taking pregabalin?

    <p>Increased risk of drowsiness with alcohol.</p> Signup and view all the answers

    What dosage form of clonazepam is recommended for pediatric patients according to RCPCH and NPPG?

    <p>Liquid formulation of 2 mg/5 mL</p> Signup and view all the answers

    Which side effect is generally not associated with benzodiazepines?

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

    In which case should the use of pregabalin be avoided?

    <p>History of substance abuse</p> Signup and view all the answers

    What should be monitored in infants taking benzodiazepines?

    <p>Sedation and feeding difficulties</p> Signup and view all the answers

    What is the primary consideration before prescribing pregabalin?

    <p>Patient's history of drug abuse</p> Signup and view all the answers

    In which scenario is measuring plasma drug concentrations justified?

    <p>Worsening seizures</p> Signup and view all the answers

    What is a major contraindication for using clonazepam?

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

    What dosage should an adult patient initially receive when starting antiepileptic treatment with benzodiazepines?

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

    What should be considered when switching oral formulations in epilepsy treatment?

    <p>Seizure history and treatment history</p> Signup and view all the answers

    What side effect is commonly associated with the use of clonazepam during pregnancy?

    <p>Depressed neonatal respiration</p> Signup and view all the answers

    What is the typical initial dosage of clobazam for a child aged 1-4 years?

    <p>250 micrograms once daily</p> Signup and view all the answers

    What is the risk factor associated with using thiopental sodium?

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

    What duration for increasing doses of clonazepam is recommended after the initial prescription?

    <p>2-4 weeks</p> Signup and view all the answers

    What is the maximum dosage of Vigabatrin for adults?

    <p>500 mg per day</p> Signup and view all the answers

    When should visual field testing be performed for patients on Vigabatrin?

    <p>Before treatment and at 6-month intervals</p> Signup and view all the answers

    For children aged 6-17, what is the initial dosage of Vigabatrin?

    <p>1 mg/kg once daily</p> Signup and view all the answers

    Which patient group requires close monitoring due to the risk of suicidal thoughts while on Vigabatrin?

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

    What is a notable persistent side effect of Vigabatrin that is of significant concern?

    <p>Visual field defects</p> Signup and view all the answers

    In which seizures is Vigabatrin indicated as a treatment option?

    <p>Myoclonic and tonic seizures</p> Signup and view all the answers

    What dosage adjustment should be made for adults taking Vigabatrin who are not receiving potent inducers of CYP3A4?

    <p>Increase at 2-week intervals</p> Signup and view all the answers

    What important safety information should patients be alerted about when taking Vigabatrin?

    <p>Potential for visual field defects</p> Signup and view all the answers

    Which side effect was noted to be very rare in patients taking Vigabatrin?

    <p>Suicidal behavior</p> Signup and view all the answers

    What factor should be taken into consideration when prescribing Vigabatrin?

    <p>History of renal disease</p> Signup and view all the answers

    What is the initial recommended dosage of Vigabatrin in adults for focal seizures?

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

    What primary caution should be taken for patients on zonisamide?

    <p>Monitor for signs of dehydration</p> Signup and view all the answers

    What treatment is recommended for children diagnosed with infantile spasms?

    <p>Vigabatrin monotherapy</p> Signup and view all the answers

    What should patients and carers be advised to do regarding new visual symptoms while on Vigabatrin?

    <p>Report them for an urgent ophthalmological opinion</p> Signup and view all the answers

    What is the recommended age range for the use of valproate medicines in children?

    <p>1 month to 11 years</p> Signup and view all the answers

    When can valproate be used in women and girls of childbearing potential?

    <p>Only when other treatments are ineffective or not tolerated</p> Signup and view all the answers

    What should pharmacists do each time they dispense valproate medicines?

    <p>Discuss pregnancy risks with female patients</p> Signup and view all the answers

    Which of the following is a common side effect of valproate?

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

    What action should specialists take under the Pregnancy Prevention Programme for female patients on valproate?

    <p>Complete and sign the Risk Acknowledgement Form and ensure it’s given to the patient</p> Signup and view all the answers

    Which statement about the Pregnancy Prevention Programme is accurate?

    <p>All female patients must be actively involved in compliance checks</p> Signup and view all the answers

    What is a requirement for prescribers when considering valproate for migraine prophylaxis?

    <p>Ensure there are no suitable alternative treatments available</p> Signup and view all the answers

    What is a notable risk associated with the use of valproate during pregnancy?

    <p>Neurological disorders in the offspring</p> Signup and view all the answers

    How should valproate medicines be dispensed according to the latest guidance?

    <p>In whole packs whenever possible</p> Signup and view all the answers

    What additional support is required for patients taking valproate under the Pregnancy Prevention Programme?

    <p>Information regarding contraception and risk acknowledgment</p> Signup and view all the answers

    What condition must be met for the use of valproate in pregnancy?

    <p>No suitable alternative treatment is available</p> Signup and view all the answers

    What is a significant risk associated with the breastfeeding of infants by mothers on valproate?

    <p>Hematological disorders in breast-fed newborns</p> Signup and view all the answers

    Which side effect is specifically mentioned as very rare in relation to valproate consumption?

    <p>Cerebral atrophy</p> Signup and view all the answers

    What is the recommended initial dosage of Zonisamide for children aged 1 month to 11 years?

    <p>20 mg/kg, then 2.5-5 mg/kg 1-2 times a day</p> Signup and view all the answers

    Which of the following side effects is least commonly associated with phenobarbital?

    <p>Impaired respiratory function</p> Signup and view all the answers

    What dosage schedule is recommended for children aged 12-17 years using Zonisamide?

    <p>20 mg/kg, then 300 mg twice daily</p> Signup and view all the answers

    What major concern should be taken into account when prescribing benzodiazepines for epilepsy treatment?

    <p>They can cause severe sedation in infants</p> Signup and view all the answers

    Which of the following medications is partially converted to phenobarbital?

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

    What is the advised maximum rate for intravenous administration of Zonisamide in children?

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

    What should be monitored to ensure effective treatment with phenobarbital?

    <p>Plasma concentration levels</p> Signup and view all the answers

    Which condition may worsen due to the use of phenobarbital?

    <p>Lennox-Gastaut syndrome</p> Signup and view all the answers

    What is an important precaution to consider in pregnant patients using antiepileptics?

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

    What variation may occur with different formulations of antiepileptic medications?

    <p>Variation in bioavailability</p> Signup and view all the answers

    Which of the following is NOT a side effect associated with phenobarbital?

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

    What is the precaution regarding benzodiazepines in breastfeeding mothers?

    <p>They may present in breast milk and should be avoided</p> Signup and view all the answers

    What is the recommended dosage adjustment for infants taking Primidone?

    <p>Maintain at 250-375 mg twice daily</p> Signup and view all the answers

    What patient population is at risk for seizure exacerbation when using Tiagabine?

    <p>Patients with absence or myoclonic seizures</p> Signup and view all the answers

    Which of the following side effects is NOT associated with the use of topiramate?

    <p>Mood stabilization</p> Signup and view all the answers

    What specific caution is advised regarding topiramate during pregnancy?

    <p>It should only be used if it offers more benefit than risk</p> Signup and view all the answers

    In patients with mild to moderate impairment, what is the best approach regarding topiramate dosage adjustments?

    <p>Implement dose reduction and/or longer dose intervals</p> Signup and view all the answers

    Which condition should prompt avoidance of topiramate?

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

    What is a significant concern regarding prenatal exposure to topiramate?

    <p>Increased risk of autism spectrum disorders</p> Signup and view all the answers

    Which symptom is commonly associated with the use of topiramate?

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

    When transitioning between different formulations of topiramate, what should be considered?

    <p>Seizure frequency and treatment history</p> Signup and view all the answers

    What is the typical initial dosage of topiramate for children aged 6-17 years?

    <p>0.5-1 mg/kg once daily</p> Signup and view all the answers

    Which formulation of topiramate is typically recommended for administration?

    <p>TOPAMAX® capsules</p> Signup and view all the answers

    What potential serious side effect is associated with the use of topiramate?

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

    What dosage adjustment strategy should be implemented in patients with severe hepatic impairment when using Tiagabine?

    <p>It should be cautiously avoided</p> Signup and view all the answers

    What is the risk associated with vigabatrin when prescribed for focal seizures?

    <p>Worsening of generalized seizures</p> Signup and view all the answers

    What is true about the treatment strategy for children aged 1 to 23 months with focal seizures?

    <p>Vigabatrin is generally indicated</p> Signup and view all the answers

    What effect does the accumulation of midazolam in adipose tissue primarily have on patient sedation?

    <p>It leads to prolonged sedation, especially in certain patients.</p> Signup and view all the answers

    What is a critical reason for ensuring flumazenil is available when using midazolam?

    <p>To reverse the effects of midazolam if needed.</p> Signup and view all the answers

    Which of the following conditions is NOT advised against when prescribing buspirone?

    <p>Chronic fatigue syndrome</p> Signup and view all the answers

    Why should healthcare professionals be cautious when prescribing benzodiazepines with opioids?

    <p>There is an increased risk of sedation and respiratory depression.</p> Signup and view all the answers

    What consequence can occur from the long-term use of benzodiazepines during pregnancy?

    <p>Higher risk of neonatal withdrawal symptoms.</p> Signup and view all the answers

    Which of the following is a major side effect of benzodiazepines?

    <p>Drowsiness and decreased alertness.</p> Signup and view all the answers

    In what situation is the use of high-strength midazolam most indicated?

    <p>Restricted to specific high-risk situations.</p> Signup and view all the answers

    What should patients be warned about after sedation with midazolam?

    <p>They should avoid skilled tasks for at least 24 hours.</p> Signup and view all the answers

    When is the recommended dose reduction for buspirone particularly indicated?

    <p>When using with potent inhibitors of CYP3A4.</p> Signup and view all the answers

    What recommendation is given to patients after administration of sedatives and analgesics?

    <p>They must be warned about the risks of skilled tasks.</p> Signup and view all the answers

    What concern is raised regarding the use of benzodiazepines in the elderly?

    <p>They are at higher risk of adverse reactions.</p> Signup and view all the answers

    What is the significance of adjusting doses for patients with renal impairment when prescribing midazolam?

    <p>It reduces risk of overdosing due to increased sensitivity.</p> Signup and view all the answers

    What should be considered when determining the dosage for midazolam in patients with hepatic impairment?

    <p>Mild to moderate impairment necessitates cautious dose reduction.</p> Signup and view all the answers

    What advice is given regarding the consumption of alcohol after receiving sedatives?

    <p>It should be avoided to reduce the risk of respiratory depression.</p> Signup and view all the answers

    What should patients be warned about after receiving sedatives and analgesics during outpatient procedures?

    <p>Risks of driving and skilled tasks</p> Signup and view all the answers

    What is a recommended dosage of benzodiazepines for children aged 1 month to 11 years?

    <p>100 micrograms/kg for one dose</p> Signup and view all the answers

    What kind of preparations should not be used in areas performing conscious sedation?

    <p>High-strength preparations</p> Signup and view all the answers

    Which of the following statements about benzodiazepines is incorrect?

    <p>They are safe for untrained personnel to administer.</p> Signup and view all the answers

    What should be monitored closely during parenteral administration of benzodiazepines?

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

    What is the maximum recommended dosage for benzodiazepines in a 24-hour period for intensive care patients?

    <p>20-40 mg/24 hours</p> Signup and view all the answers

    What is a significant risk of using benzodiazepines during breastfeeding?

    <p>Benzodiazepines presence in milk</p> Signup and view all the answers

    How should midazolam be used in children for seizure treatment?

    <p>Dilute with sodium chloride for intravenous use.</p> Signup and view all the answers

    What does flumazenil do when used with midazolam?

    <p>Reverses its effects if necessary</p> Signup and view all the answers

    What precaution should be taken when administering benzodiazepines to elderly patients?

    <p>Dosage should be based on their response.</p> Signup and view all the answers

    Which is a common side effect of benzodiazepines?

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

    What should be the dilution for intramuscular use of benzodiazepines in adults?

    <p>Dilute with an equal volume of water for injections or saline</p> Signup and view all the answers

    Which aspect is NOT included as a contraindication for benzodiazepines?

    <p>Stable heart conditions</p> Signup and view all the answers

    What is the maximum daily dosage recommended for debilitated patients under short-term anxiety treatment?

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

    Which condition is explicitly listed as a contraindication for the use of benzodiazepines?

    <p>Organic brain changes</p> Signup and view all the answers

    What is the advised dosage for treating alcohol withdrawal in moderate dependence in adults?

    <p>10-30 mg</p> Signup and view all the answers

    Which side effect is classified as very rare when using benzodiazepines?

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

    What voltage is recommended for the administration rate of intravenous benzodiazepines?

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

    Which of the following should be avoided if possible during breastfeeding?

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

    What is the advised dosage for acute muscle spasm treatment in adults?

    <p>10 mg, then another 10 mg after 4 hours</p> Signup and view all the answers

    What is the role of diazepam in musculoskeletal conditions?

    <p>Used for muscle spasms and anxiety</p> Signup and view all the answers

    What is the dosage range for children with tetanus?

    <p>100-300 micrograms/kg</p> Signup and view all the answers

    Which situation requires special precautions when using intravenous benzodiazepines?

    <p>High risk of respiratory depression</p> Signup and view all the answers

    What is a common interaction that may occur with benzodiazepines?

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

    What is the maximum concentration limit for intravenous diamorphine in adults?

    <p>200 mg in 500 mL</p> Signup and view all the answers

    What is the advised dosage for anxiety treatment in adults?

    <p>2 mg three times a day</p> Signup and view all the answers

    Which of the following treatments is appropriate for anxiety disorders in elderly patients?

    <p>5 mg three times a day</p> Signup and view all the answers

    What is the initial recommended dosage of Concerta® XL for children aged 6-17?

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

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

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

    What monitoring measure is essential for patients receiving treatment with atomoxetine?

    <p>Monitoring for anxiety and depression</p> Signup and view all the answers

    What is the highest licensed daily dosage of a standard stimulatory medication for ADHD when prescribed under specialist direction?

    <p>90 mg</p> Signup and view all the answers

    Which of the following conditions can be a contraindication for using methylphenidate?

    <p>Anorexia nervosa</p> Signup and view all the answers

    What should be done if a patient exhibits signs of suicidal ideation while on atomoxetine?

    <p>Consult a specialist and monitor closely</p> Signup and view all the answers

    When switching from immediate-release to modified-release preparations, which factor is NOT critical to consider?

    <p>Presence of renal disease</p> Signup and view all the answers

    For adults starting treatment with methylphenidate, what is the approximate recommended initial dosing?

    <p>5 mg 2-3 times a day</p> Signup and view all the answers

    What proportion of the dosage should be taken by patients with moderate hepatic impairment when treated with atomoxetine?

    <p>Half dose</p> Signup and view all the answers

    What type of preparation is specifically mentioned for patients unable to take medications orally?

    <p>Atomoxetine oral suspension</p> Signup and view all the answers

    Which of the following is a reported side effect of atomoxetine?

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

    What is the typical usual dosage of methylphenidate for treating narcolepsy?

    <p>10-60 mg daily</p> Signup and view all the answers

    What significant action should patients and their carers be informed of regarding atomoxetine?

    <p>To recognize symptoms of hepatic impairment</p> Signup and view all the answers

    What medication is recommended for the treatment of ADHD in children aged 6 years and older?

    <p>Atomoxetine oral solution</p> Signup and view all the answers

    Which of the following side effects is extremely rare and associated with amfetamines?

    <p>Hepatic coma</p> Signup and view all the answers

    What monitoring requirement should be followed during the initial treatment of children with ADHD?

    <p>Monitor growth and aggressive behavior</p> Signup and view all the answers

    Which medication form of amfetamines is recommended to be taken with soft food or liquids?

    <p>Modified-release capsules</p> Signup and view all the answers

    Which side effect might be expected from an overdose of amfetamines?

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

    What specific caution is advised for patients with a history of tics when taking amfetamines?

    <p>Potential for tic exacerbation</p> Signup and view all the answers

    What is the initial recommended daily dose of Lisdexamfetamine for treating ADHD in adults?

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

    In the case of severe renal impairment, what is the maximum daily dosage adjustment for amfetamines?

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

    Which of the following should be monitored during treatment for psychiatric symptoms?

    <p>Aggressiveness and hostility over time</p> Signup and view all the answers

    Which of the following conditions can lead to contraindications for amfetamines?

    <p>Advanced arteriosclerosis</p> Signup and view all the answers

    What patient population is advised to avoid using amfetamines during pregnancy?

    <p>All pregnant patients</p> Signup and view all the answers

    What is a key instruction regarding the withdrawal from amfetamines?

    <p>Cessation should be gradual</p> Signup and view all the answers

    Which of the following is not a commonly reported side effect of amfetamines?

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

    What serious cardiovascular condition should be considered before prescribing amfetamines?

    <p>Severe hypertension</p> Signup and view all the answers

    What is the recommended action if a patient experiences hallucinations while taking amfetamines?

    <p>Consult a healthcare provider promptly</p> Signup and view all the answers

    What is one potential paradoxical effect of benzodiazepines?

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

    Which medication forms are commonly available for Diazepam?

    <p>Tablet and oral solution</p> Signup and view all the answers

    How long can the risk of adverse effects from intravenous benzodiazepines last after administration?

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

    What is a common behavioral disorder associated with hyperactivity and impulsivity?

    <p>Attention deficit hyperactivity disorder (ADHD)</p> Signup and view all the answers

    What age group typically shows symptoms of ADHD?

    <p>3-7 years</p> Signup and view all the answers

    Which of the following is NOT a contraindication for taking Diazepam?

    <p>Sleep apnea</p> Signup and view all the answers

    What approach should be taken when symptoms persist in ADHD patients despite environmental modifications?

    <p>Consider drug treatment in combination with non-drug treatments</p> Signup and view all the answers

    Which psychological intervention may be effective for patients with ADHD who refuse drug treatment?

    <p>Cognitive behavioral therapy (CBT)</p> Signup and view all the answers

    What is the recommended initial dose of atomoxetine for children?

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

    Which side effect is associated with atomoxetine usage?

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

    In adults, what is the maintenance dose recommendation for atomoxetine after response adjustments?

    <p>80-100 mg daily</p> Signup and view all the answers

    What factor typically does NOT improve ADHD symptoms?

    <p>Unstructured environment</p> Signup and view all the answers

    Which condition is NOT commonly associated with ADHD?

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

    Which contraindications are associated with atomoxetine?

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

    What proportion of the dose in Concerta XL is made up of the modified-release component?

    <p>78%</p> Signup and view all the answers

    Which of the following medications contains an immediate-release component that constitutes 50% of the dose?

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

    What should be monitored to assess potential growth restriction in children undergoing prolonged therapy with methylphenidate?

    <p>Height and weight</p> Signup and view all the answers

    What is a significant warning associated with the cessation of methylphenidate treatment?

    <p>Treatment should not be stopped abruptly.</p> Signup and view all the answers

    Which condition is NOT considered a psychiatric disorder that may require careful evaluation when using methylphenidate?

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

    What side effect is commonly associated with the use of methylphenidate?

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

    Which factor does NOT need to be monitored when prescribing methylphenidate?

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

    What is the immediate-release component percentage in Equisym XL?

    <p>30%</p> Signup and view all the answers

    Which interaction is commonly concerning for patients on methylphenidate?

    <p>Benzodiazepines causing increased sedation</p> Signup and view all the answers

    What should prescribers do to prevent confusion between different formulations of methylphenidate?

    <p>Specify the brand or manufacturer name.</p> Signup and view all the answers

    Which formulation of methylphenidate has the lowest percentage for its immediate-release component?

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

    In what scenario should the use of methylphenidate be continued despite new psychiatric symptoms?

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

    What effect on behavior can prolonged use of methylphenidate potentially have?

    <p>Altered mood</p> Signup and view all the answers

    What cardiovascular issue should be monitored in patients taking methylphenidate?

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

    What is the maximum daily dose of Lisdexamfetamine recommended for patients with severe renal impairment?

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

    Which populations are primarily recommended for treatment with Lisdexamfetamine?

    <p>Children aged 6-17 years and adults aged 60-70 years</p> Signup and view all the answers

    What symptoms should be monitored during the initial treatment with Lisdexamfetamine?

    <p>Aggressive behavior and gastrointestinal discomfort</p> Signup and view all the answers

    Which of the following is NOT a recommended practice when administering Lisdexamfetamine capsules?

    <p>Dissolving the contents in acidic beverages only</p> Signup and view all the answers

    What is a common side effect experienced during the first weeks of treatment with guanfacine?

    <p>Somnolence and sedation</p> Signup and view all the answers

    When managing overdose symptoms of Lisdexamfetamine, which of the following is a possible effect?

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

    Which aspect is key in monitoring patients on guanfacine during dosage adjustments?

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

    Which precaution is specifically advised for females of childbearing potential when taking certain medications?

    <p>Effective contraception measures should be taken</p> Signup and view all the answers

    What should be done to manage withdrawal effects when stopping treatment with guanfacine?

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

    What should healthcare professionals monitor in children during Lisdexamfetamine treatment?

    <p>Height, weight, and appetite every 6 months</p> Signup and view all the answers

    Under what circumstance should patients with bipolar disorder be treated?

    <p>With antimanic drugs after referral to a specialist</p> Signup and view all the answers

    What indicates a contraindication for the use of antidepressants in bipolar disorder treatment?

    <p>Rapid-cycling bipolar disorder</p> Signup and view all the answers

    What is the recommended initial monitoring for patients starting treatment with guanfacine?

    <p>Risk factors for arrhythmia and hypotension</p> Signup and view all the answers

    What is an important consideration for elderly patients when prescribing centrally-acting antihypertensives?

    <p>Consider alternative classes of antihypertensives first</p> Signup and view all the answers

    What should be done to reduce the risk of recurrence when discontinuing antipsychotic drugs?

    <p>Gradually reduce the dose over at least 4 weeks.</p> Signup and view all the answers

    Which statement about the usage of valproate in women of childbearing potential is accurate?

    <p>It should only be used if other treatments are ineffective.</p> Signup and view all the answers

    Which medication is indicated for both the treatment of acute mania and the long-term management of bipolar disorder?

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

    What is the primary reason benzodiazepines should not be used for extended periods in the treatment of behavioral disturbances?

    <p>They can lead to tolerance and dependence.</p> Signup and view all the answers

    Which drug is contraindicated for migraine prophylaxis in patients with bipolar disorder?

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

    What is a potential risk of using semisodium valproate in women of childbearing age?

    <p>Teratogenic effects and neurodevelopmental disorders.</p> Signup and view all the answers

    Which medication is classified under the second-generation antipsychotics for treating moderate to severe manic episodes?

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

    What is the role of carbamazepine in the treatment of bipolar disorder?

    <p>Long-term management for patients unresponsive to lithium.</p> Signup and view all the answers

    What is the maximum recommended dosage of Reboxetine per day?

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

    Which side effect is associated with long-term use of Reboxetine?

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

    Reboxetine should be prescribed with caution in patients with which condition?

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

    What potential risk arises from using SSRIs during the month before delivery?

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

    Which symptom is NOT typically associated with overdose of selective serotonin re-uptake inhibitors?

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

    Which of the following drugs also increases the risk of bleeding due to its effect on platelet function?

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

    What condition is a contraindication for the use of SSRIs?

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

    Which of the following is a common side effect reported for medications like Cipramil®?

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

    What advice is recommended regarding the use of anticoagulant medication in women at high risk of thrombotic events?

    <p>It should not be stopped</p> Signup and view all the answers

    Which of the following disorders requires particular caution when prescribing SSRIs?

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

    How is the dose of Reboxetine typically adjusted based on clinical needs?

    <p>Increased gradually to 10 mg daily</p> Signup and view all the answers

    Which serious adverse effect is associated with the use of SSRIs?

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

    In patients with renal impairment, what is advised regarding the use of Reboxetine?

    <p>Dose adjustments are advised</p> Signup and view all the answers

    What is a possible effect of abrupt cessation of Reboxetine treatment?

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

    What is the primary responsibility of GPs concerning women and girls of childbearing potential on valproate?

    <p>Ensure enrollment in the Pregnancy Prevention Programme</p> Signup and view all the answers

    What should specialists do at least annually for women and girls under the Pregnancy Prevention Programme?

    <p>Book in-review appointments and evaluate treatments</p> Signup and view all the answers

    When dispensing valproate medicines, pharmacists must ensure to do what each time?

    <p>Discuss the risks of pregnancy with female patients</p> Signup and view all the answers

    How should valproate be administered if used during pregnancy?

    <p>In divided doses at the lowest effective dose</p> Signup and view all the answers

    Which of the following is NOT considered a contraindication for valproate?

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

    What is recommended for clinicians supporting patients taking valproate during the COVID-19 pandemic?

    <p>Refer to temporary guidance issued by the MHRA</p> Signup and view all the answers

    What should patients or their carers be taught regarding signs of serious side effects from valproate?

    <p>To seek immediate medical attention for specific symptoms</p> Signup and view all the answers

    In what form is asenapine recommended for administration?

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

    What is the maximum daily dosage of paroxetine for obsessive-compulsive disorder treatment?

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

    What is the advised dosage escalation for adults starting on acetylcholinesterase inhibitors?

    <p>5 mg twice daily, with adjustments based on response</p> Signup and view all the answers

    What potential side effect is associated with the use of sertraline?

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

    Which side effect is considered rare or very rare for paroxetine?

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

    What potential adverse effects should be monitored when prescribing valproate?

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

    For patients with bipolar disorder, which medication may be considered as an alternative to valproate?

    <p>Asenapine if potential benefit outweighs risks</p> Signup and view all the answers

    What is the initial recommended dosage of duloxetine for adults?

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

    What specific monitoring should be initiated during prenatal care if a patient has taken valproate?

    <p>Senior prenatal monitoring</p> Signup and view all the answers

    In patients with renal impairment, what caution should be taken for paroxetine?

    <p>Use with caution if creatinine clearance is less than 30 mL/min</p> Signup and view all the answers

    How should treatment be adjusted if withdrawal symptoms emerge after paroxetine discontinuation?

    <p>Reduce the dose gradually over 4 weeks or longer</p> Signup and view all the answers

    What is a potential risk of breastfeeding while on valproate medications?

    <p>Haematological disorders in newborns</p> Signup and view all the answers

    What is the maximum daily dosage for sertraline for adult patients?

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

    What should be done if a patient does not respond to duloxetine after two months?

    <p>Discontinue the dosage and review treatment</p> Signup and view all the answers

    What type of disorder could be a side effect of sertraline?

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

    What is an essential counseling point for patients prescribed paroxetine?

    <p>There may be effects on driving and skilled tasks</p> Signup and view all the answers

    Which of the following conditions is duloxetine NOT recommended for?

    <p>Severe anxiety disorder</p> Signup and view all the answers

    Which medication can potentially cause persistent sexual dysfunction symptoms after treatment has stopped?

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

    What condition may breastfeeding affect in terms of medication impact?

    <p>Congenital malformations</p> Signup and view all the answers

    What is the recommended serum-lithium concentration range for elderly patients during maintenance therapy?

    <p>0.4-1.0 mmol/litre</p> Signup and view all the answers

    Which patient demographic is monitored more frequently when receiving lithium treatment?

    <p>Patients over 65 years old</p> Signup and view all the answers

    What potential side effect of lithium treatment is described as rare but serious?

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

    In the case of abrupt discontinuation of lithium, what is a recommended alternative therapy?

    <p>Atypical antipsychotic or valproate</p> Signup and view all the answers

    How often should routine serum-lithium monitoring be performed during the first year after treatment initiation?

    <p>Every 3 months</p> Signup and view all the answers

    What is the primary purpose of monitoring serum-lithium concentrations?

    <p>To avoid toxicity and optimize dosing</p> Signup and view all the answers

    Which form of lithium is associated with a higher initial dose for adults weighing over 50 kg?

    <p>LISKONUM®</p> Signup and view all the answers

    What is a recommended approach for patients in remission from depression who are at higher risk of relapse after psychological treatment?

    <p>Continue psychological therapy</p> Signup and view all the answers

    What should patients receiving lithium be advised to maintain to prevent toxicity?

    <p>Adequate fluid intake</p> Signup and view all the answers

    What is the advised monitoring frequency for body weight or BMI during lithium treatment?

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

    Why are SSRIs often preferred over tricyclic antidepressants?

    <p>They are better tolerated and safer in overdose</p> Signup and view all the answers

    Which condition is a contraindication for the use of lithium salts?

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

    What is the recommended monitoring frequency for patients starting on antidepressant treatments?

    <p>Every week or two for the first few weeks</p> Signup and view all the answers

    In managing acute anxiety, which medication is commonly used?

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

    For patients diagnosed with QT interval prolongation, what is the recommendation regarding lithium treatment?

    <p>Avoid lithium completely</p> Signup and view all the answers

    What is the primary danger associated with monoamine oxidase inhibitors (MAOIs)?

    <p>They are associated with dietary and drug interaction risks</p> Signup and view all the answers

    What precaution is advised for women of childbearing potential during lithium treatment?

    <p>Effective contraception and monitoring for pregnancy</p> Signup and view all the answers

    What is a significant risk factor to monitor in patients under treatment for depression?

    <p>Suicidal thoughts and behaviors</p> Signup and view all the answers

    What should be assessed before initiating lithium treatment?

    <p>Cardiac, renal, and thyroid function tests</p> Signup and view all the answers

    What individual characteristic may lead to an adjusted dosage of lithium?

    <p>Age and body weight</p> Signup and view all the answers

    Which antidepressant category tends to have a dual action on serotonin and noradrenaline reuptake?

    <p>Tricyclic and related antidepressants</p> Signup and view all the answers

    Which condition may benefit from therapy with either clomipramine or imipramine?

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

    What should be done for patients experiencing serotonin syndrome?

    <p>Withdraw serotonergic medication and seek specialist advice</p> Signup and view all the answers

    How long should antidepressant treatment generally continue after achieving remission?

    <p>For a minimum of 6 months</p> Signup and view all the answers

    For chronic anxiety treatment lasting longer than 4 weeks, which type of medication is often appropriate?

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

    What is often the first-line treatment for patients with generalized anxiety disorder?

    <p>Psychological treatment</p> Signup and view all the answers

    What should be considered for patients unresponsive to SSRIs or SNRIs?

    <p>Consider alternative drug treatments in specialist settings</p> Signup and view all the answers

    Which population should start initial doses of tricyclic antidepressants at lower levels?

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

    What is the recommended waiting period before starting another MAOI after discontinuing a previous MAOI?

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

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

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

    What is a potential risk when MAOIs are combined with other antidepressants?

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

    What dosage adjustment is recommended for elderly patients when prescribing MAOIs?

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

    What is an important precaution for patients taking moclobemide?

    <p>Avoid tyramine-rich foods</p> Signup and view all the answers

    Which of the following symptoms is a potential withdrawal symptom after stopping antidepressants?

    <p>Vivid dreams</p> Signup and view all the answers

    What should patients be warned about regarding the side effects of Nardil?

    <p>Potential for hepatocellular injury</p> Signup and view all the answers

    Which antidepressant functionally inhibits monoamine oxidase type A in a reversible manner?

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

    What is a major side effect that patients should be monitored for when taking antidepressants?

    <p>Suicidal thoughts and behavior</p> Signup and view all the answers

    What is the primary reason patients should only consume fresh foods while on MAOIs?

    <p>To minimize interactions with tyramine</p> Signup and view all the answers

    What is the starting dosage for adult patients prescribed Nardil?

    <p>10 mg twice daily</p> Signup and view all the answers

    What medication is primarily used as a selective inhibitor of noradrenaline re-uptake?

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

    How long might it take for treatment responses to become maximal with certain antidepressants?

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

    What dosage increase is permissible for MAOIs after 4 weeks if necessary?

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

    What is one of the potential side effects of lithium citrate that can lead to further complications?

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

    Which form of lithium citrate offers a dosage of 104 mg per 1 ml?

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

    Which factor does NOT contribute as a risk factor for developing depression?

    <p>Consistent exercise</p> Signup and view all the answers

    What is the typical duration criteria for defining chronic depressive symptoms?

    <p>At least two years</p> Signup and view all the answers

    When should patients receiving antidepressant treatment be monitored for suicidal ideation?

    <p>In the early weeks of treatment</p> Signup and view all the answers

    What is a potential first-line treatment option for patients with subthreshold or mild depression?

    <p>Psychological therapy</p> Signup and view all the answers

    What is the main goal of treating depression?

    <p>Improve mood and quality of life</p> Signup and view all the answers

    Which type of antidepressant is generally well-tolerated and has a good safety profile?

    <p>Serotonin reuptake inhibitors (SSRIs)</p> Signup and view all the answers

    What factor should be assessed if a patient has not responded to antidepressant treatment after 4 weeks?

    <p>Treatment adherence</p> Signup and view all the answers

    What should patients and their families be encouraged to monitor during treatment for depression?

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

    Which of the following treatments is indicated for managing severe depression?

    <p>Combination therapy with an antidepressant and CBT</p> Signup and view all the answers

    What is a common lifestyle change encouraged for improving well-being in patients with depression?

    <p>Regular physical activity</p> Signup and view all the answers

    What should be discussed before starting treatment for depression during pregnancy?

    <p>The risks and benefits of treatments</p> Signup and view all the answers

    What is the recommended approach if a patient experiences limited response to psychological monotherapy?

    <p>Add an SSRI or switch to an SSRI alone</p> Signup and view all the answers

    What is a potential risk associated with the use of SSRIs during early pregnancy?

    <p>Increased risk of congenital heart defects</p> Signup and view all the answers

    What is the recommended initial dosage of escitalopram for elderly individuals?

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

    What withdrawal symptoms may occur after stopping the use of SSRIs?

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

    What specific advice is given for mixing oral drops of Cipramil®?

    <p>Mix with water, orange juice, or apple juice</p> Signup and view all the answers

    What side effect is common with SSRI medications?

    <p>Bone fracture</p> Signup and view all the answers

    What is advised regarding treatment for patients with hepatic impairment when using citalopram?

    <p>Gradual dose reduction is recommended</p> Signup and view all the answers

    How long should the dosage reduction last after stopping the use of antidepressant drugs?

    <p>4 weeks</p> Signup and view all the answers

    What should patients be counseled about regarding driving while using SSRIs?

    <p>It can impair their performance</p> Signup and view all the answers

    What is indicated for the dosage adjustment of escitalopram for social anxiety disorder?

    <p>Adjust dosage after 2-4 weeks</p> Signup and view all the answers

    Which side effect may occur with withdrawal from fluoxetine?

    <p>Electric shock sensation</p> Signup and view all the answers

    What form of fluoxetine is used for menopausal symptoms in women with breast cancer?

    <p>20 mg once daily</p> Signup and view all the answers

    What is one of the common side effects of escitalopram?

    <p>Common sinusitis</p> Signup and view all the answers

    What counseling is advised for patients taking oral drops of SSRIs?

    <p>Counsel on administration and effects on driving</p> Signup and view all the answers

    What is a key consideration for using venlafaxine in pregnant patients?

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

    Which drug is contraindicated in patients with breast cancer for the treatment of menopausal symptoms?

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

    What is the maximum recommended dosage for venlafaxine when treating major depression?

    <p>375 mg per day</p> Signup and view all the answers

    For generalized anxiety disorder, what is the maximum dosage of venlafaxine recommended?

    <p>225 mg daily</p> Signup and view all the answers

    Which medication is a serotonin and noradrenaline re-uptake inhibitor (SNRI) used in anxiety and depression treatment?

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

    What side effect is notably associated with the use of SNRIs like venlafaxine?

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

    What advice should be given regarding the use of antidepressants like venlafaxine prior to delivery?

    <p>There is an increased risk of postpartum hemorrhage.</p> Signup and view all the answers

    What is a common withdrawal symptom associated with SNRI treatment discontinuation?

    <p>Tremors and dizziness</p> Signup and view all the answers

    Which condition is NOT a contraindication for venlafaxine use?

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

    How should venlafaxine be prescribed for menopausal symptoms in women with breast cancer?

    <p>It should not be prescribed.</p> Signup and view all the answers

    What is the advised maximum dose for venlafaxine when treating menopausal symptoms?

    <p>75 mg once daily</p> Signup and view all the answers

    What is a potential side effect of SNRIs regarding neurological health?

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

    Which condition requires caution when prescribing tricyclic antidepressants?

    <p>Chronic constipation</p> Signup and view all the answers

    What condition requires caution when prescribing duloxetine due to potential renal impairment?

    <p>Chronic renal disease</p> Signup and view all the answers

    What is a potential side effect of tricyclic antidepressants that affects mental state?

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

    What group of antidepressants does venlafaxine belong to?

    <p>Selective serotonin and norepinephrine reuptake inhibitors</p> Signup and view all the answers

    What is a recommended action when discontinuing tricyclic antidepressants?

    <p>Gradually reduce the dose over 4 weeks</p> Signup and view all the answers

    Which of the following is a common withdrawal symptom from tricyclic antidepressants?

    <p>Difficulty concentrating</p> Signup and view all the answers

    Which condition is contraindicated for patients prescribed tricyclic-related antidepressants?

    <p>Recent myocardial infarction</p> Signup and view all the answers

    What effect can tricyclic antidepressants have on blood pressure?

    <p>Cause postural hypotension</p> Signup and view all the answers

    Which neurotransmitters are primarily influenced by Mirtazapine?

    <p>Norepinephrine and serotonin</p> Signup and view all the answers

    What is a significant risk associated with the overdose of tricyclic antidepressants?

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

    What monitoring frequency is recommended during the first three months of treatment with tricyclic antidepressants?

    <p>Full blood count every 4 weeks</p> Signup and view all the answers

    For which condition should tricyclic antidepressants be prescribed with extreme caution due to an increase in suicide risk?

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

    Which of the following side effects is most commonly associated with tricyclic antidepressants in elderly patients?

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

    Which side effect is least likely to occur with tricyclic-related antidepressants?

    <p>Positive impact on mood</p> Signup and view all the answers

    What is advised regarding the use of tricyclic antidepressants during pregnancy?

    <p>Should be avoided due to limited information</p> Signup and view all the answers

    What should be closely monitored in patients taking antidepressants for the first few months?

    <p>Psychiatric and cardiac side effects</p> Signup and view all the answers

    Which of the following antipsychotic drugs is associated with the lowest risk of causing weight gain?

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

    What is a common cardiovascular side effect of antipsychotic medications during initial dose titration?

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

    Which condition is NOT a potential risk associated with prescribing dosulepin hydrochloride?

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

    Which of these antipsychotic drugs is least likely to cause diabetes?

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

    What is a major cause of sexual dysfunction in patients treated with antipsychotic medications?

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

    What is a common side effect of tricyclic antidepressants?

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

    Which antipsychotic drug is particularly concerning for QT-interval prolongation?

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

    Which statement about the withdrawal effects of antidepressant drugs is accurate?

    <p>Symptoms usually occur within 5 days of cessation.</p> Signup and view all the answers

    What is a notable consequence of taking second-generation antipsychotics regarding metabolic health?

    <p>Decreased insulin sensitivity</p> Signup and view all the answers

    When prescribing tricyclic antidepressants to patients with hepatic impairment, what is the recommended action?

    <p>Adjust the dosage in all cases.</p> Signup and view all the answers

    Which of the following is considered a serious potential consequence of tricyclic antidepressant overdose?

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

    Which of the following is NOT a common symptom of hyperprolactinaemia?

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

    Why should tricyclic antidepressants be prescribed in limited quantities?

    <p>Due to cardiovascular and epileptogenic effects.</p> Signup and view all the answers

    Which mechanism is NOT typically associated with antipsychotic-induced sexual dysfunction?

    <p>Blockade of serotonin receptors</p> Signup and view all the answers

    What is a significant withdrawal risk when stopping tricyclic antidepressants suddenly after long-term use?

    <p>Severe symptoms may arise.</p> Signup and view all the answers

    Which patient group is particularly susceptible to the side effects of tricyclic antidepressants?

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

    In what circumstance should tricyclic antidepressant treatment be stopped?

    <p>If the patient enters a manic phase.</p> Signup and view all the answers

    What medication-related caution should be considered for patients with prostatic hypertrophy?

    <p>Increased risk of urinary retention.</p> Signup and view all the answers

    What is a possible effect of taking tricyclic antidepressants during pregnancy?

    <p>Sedation may occur in neonates.</p> Signup and view all the answers

    Which of the following is an effect that is NOT associated with tricyclic antidepressant overdose?

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

    What specific precaution is recommended for prescribing tricyclic antidepressants to patients with a history of bipolar disorder?

    <p>Regular monitoring for mood changes is necessary.</p> Signup and view all the answers

    Which of the following represents a rare side effect of tricyclic antidepressants?

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

    What should be monitored in neonates if mirtazapine is used during pregnancy?

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

    What is a common side effect reported when treatment with antidepressants is discontinued abruptly?

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

    Which group of patients should have lower initial doses of tricyclic antidepressants due to higher susceptibility to side effects?

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

    Which of the following conditions is contraindicated for prescribing amitriptyline?

    <p>Immediate recovery after myocardial infarction</p> Signup and view all the answers

    What is the safest method recommended for discontinuing tricyclic antidepressants to minimize withdrawal symptoms?

    <p>Taper dosage gradually over weeks</p> Signup and view all the answers

    In the case of suspected blood dyscrasia during treatment, what action should be taken?

    <p>Perform blood count and stop the drug</p> Signup and view all the answers

    What serious condition is associated with overdose of amitriptyline?

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

    What should be advised to patients taking tricyclic antidepressants concerning alcohol consumption?

    <p>Alcohol can enhance drowsiness</p> Signup and view all the answers

    What is the recommended action if a patient exhibits symptoms of serotonin syndrome?

    <p>Discontinue the serotonin-targeting medication</p> Signup and view all the answers

    Which statement best describes the typical usage of tricyclic antidepressants?

    <p>Used for mild-to-moderate depression and anxiety</p> Signup and view all the answers

    Which side effect is associated with long-term usage of amitriptyline?

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

    What is a rare adverse effect that may occur with the use of tricyclic antidepressants?

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

    Which medication is specifically indicated for conditions like major depressive disorder and neuropathy?

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

    What should be done if the oral tricyclic antidepressant treatment is interrupted for several days?

    <p>Consult with a healthcare provider</p> Signup and view all the answers

    Which condition is NOT a caution when prescribing antidepressant drugs?

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

    Which of the following symptoms is associated with overdose of antidepressants?

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

    What is the recommended daily dosage range for vortioxetine in treating major depression in adults?

    <p>5-20 mg</p> Signup and view all the answers

    Which potential effect is NOT associated with withdrawal from antidepressant medications?

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

    Which risk factor is associated with increased withdrawal symptoms when stopping antidepressants?

    <p>Regular administration for 8 weeks or more</p> Signup and view all the answers

    In which patients should tryptophan be used with caution?

    <p>Patients with eosinophilia myalgia syndrome</p> Signup and view all the answers

    What dosage of tryptophan is indicated for treatment-resistant depression in adults?

    <p>1-6 g per day</p> Signup and view all the answers

    Which medication is primarily discussed for managing inappropriate sexual behavior?

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

    What is a significant side effect concern when using SSRIs and SNRIs during the late stages of pregnancy?

    <p>Risk of postpartum hemorrhage</p> Signup and view all the answers

    Which statement about the side effects of benperidol is accurate?

    <p>It may lead to extrapyramidal effects.</p> Signup and view all the answers

    Which antipsychotic-related concern is particularly noted for neonates when taken during the third trimester of pregnancy?

    <p>Extrapyramidal symptoms</p> Signup and view all the answers

    Which clinical observation is advised in high-risk patients receiving antidepressant treatment?

    <p>Close monitoring for signs of suicidal thoughts</p> Signup and view all the answers

    What aspect of psychiatric treatment is highlighted as requiring careful monitoring for patients using vortioxetine?

    <p>Observation for unusual behavior</p> Signup and view all the answers

    What characteristic makes elderly patients particularly sensitive to tricyclic antidepressants?

    <p>Higher susceptibility to side effects</p> Signup and view all the answers

    What is a potential outcome of overdose with tricyclic antidepressants?

    <p>Potentially fatal arrhythmias</p> Signup and view all the answers

    Which condition is a contraindication for the use of tricyclic antidepressants?

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

    What characteristic of tricyclic antidepressants warrants the need for a gradual reduction in dosage?

    <p>Significant risk of withdrawal symptoms</p> Signup and view all the answers

    Which symptom is NOT commonly associated with tricyclic antidepressants?

    <p>Prominent anti-inflammatory effects</p> Signup and view all the answers

    What is a recommended strategy to reduce the risk of side effects when administrating tricyclic antidepressants?

    <p>Titrate slowly to the minimum effective dose</p> Signup and view all the answers

    What is an important consideration when prescribing tricyclic antidepressants to patients with a history of cardiac issues?

    <p>Monitoring cardiac function closely</p> Signup and view all the answers

    What is a common side effect of tricyclic antidepressants that poses a risk for elderly patients?

    <p>Impaired motor coordination</p> Signup and view all the answers

    Which side effect is associated with tricyclic antidepressants and may occur during overdose?

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

    How long should the dose of tricyclic antidepressants be reduced if withdrawal symptoms arise?

    <p>4 weeks</p> Signup and view all the answers

    What is the appropriate starting point for dosing tricyclic antidepressants in elderly patients?

    <p>Minimum effective dose</p> Signup and view all the answers

    What side effect related to tricyclic antidepressants affects the gastrointestinal system?

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

    Which key concern should be monitored when treating patients with tricyclic antidepressants?

    <p>Changes in urinary function</p> Signup and view all the answers

    What is the potential effect of using tricyclic antidepressants during pregnancy?

    <p>Severe withdrawal symptoms in newborns</p> Signup and view all the answers

    Which condition is a contraindication for the use of tricyclic antidepressants?

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

    What is the recommended action to minimize the risk of withdrawal symptoms after stopping tricyclic antidepressants?

    <p>Gradually reduce the dose over 4 weeks</p> Signup and view all the answers

    Which of the following side effects is NOT typically associated with an overdose of tricyclic antidepressants?

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

    What dosage is recommended for elderly patients starting treatment with tricyclic antidepressants?

    <p>10-25 mg three times a day</p> Signup and view all the answers

    Which of the following is a common side effect of tricyclic antidepressants?

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

    What potential effect is associated with combining alcohol and tricyclic antidepressants?

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

    Which of the following should be monitored if the daily dose of nortriptyline exceeds 100 mg?

    <p>Plasma-nortriptyline concentration</p> Signup and view all the answers

    What is the primary reason for limiting the quantity of tricyclic antidepressants prescribed at one time?

    <p>Prevention of overdose incidents</p> Signup and view all the answers

    What is a significant risk associated with the rapid discontinuation of tricyclic antidepressant treatment after prolonged use?

    <p>Severe withdrawal symptoms</p> Signup and view all the answers

    What side effect might elderly patients be particularly susceptible to when taking tricyclic antidepressants?

    <p>Cardiac side effects</p> Signup and view all the answers

    Which statement is true about the side effects associated with tricyclic antidepressants?

    <p>They can include both psychiatric and cardiac effects.</p> Signup and view all the answers

    What adjustment is necessary for patients using tricyclic antidepressants and also have renal impairment?

    <p>Consider contraindications based on severity</p> Signup and view all the answers

    What is the most appropriate action when considering treatment with tricyclic antidepressants for patients with a history of bipolar disorder?

    <p>Avoid prescribing due to a risk of mood destabilization</p> Signup and view all the answers

    Which of the following side effects is linked to tricyclic antidepressants affecting the eyes?

    <p>Increased intra-ocular pressure</p> Signup and view all the answers

    Which type of antipsychotic drug primarily blocks dopamine D2 receptors in the brain?

    <p>First-generation antipsychotic drugs</p> Signup and view all the answers

    What is the primary effect of second-generation antipsychotic drugs compared to first-generation antipsychotics?

    <p>Lower risk of acute extrapyramidal symptoms</p> Signup and view all the answers

    Which symptom is categorized as a positive symptom of schizophrenia?

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

    What approach should be taken when starting treatment with an antipsychotic drug?

    <p>Begin with low doses and titrate slowly</p> Signup and view all the answers

    What is the recommended time frame for evaluating the efficacy of an antipsychotic dose?

    <p>4-6 weeks</p> Signup and view all the answers

    What is a significant risk associated with prescribing antipsychotic drugs to elderly patients?

    <p>Higher mortality rates</p> Signup and view all the answers

    Which of the following is an example of an adverse effect associated with first-generation antipsychotic drugs?

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

    What type of symptoms are extrapyramidal symptoms most closely associated with?

    <p>First-generation antipsychotic drugs</p> Signup and view all the answers

    Which intervention might be indicated for a patient exhibiting parkinsonian symptoms while on antipsychotic medication?

    <p>Review and reduce exposure to antipsychotics</p> Signup and view all the answers

    Which type of antipsychotic medication is associated with a higher likelihood of weight gain and glucose intolerance?

    <p>Atypical antipsychotics</p> Signup and view all the answers

    What is the primary therapeutic goal when treating acute schizophrenia episodes with antipsychotics?

    <p>To alleviate positive symptoms effectively</p> Signup and view all the answers

    What should be avoided unless in exceptional circumstances when prescribing antipsychotic medications?

    <p>Combination of multiple antipsychotics</p> Signup and view all the answers

    Which medication class includes amisulpride and clozapine?

    <p>Atypical antipsychotics</p> Signup and view all the answers

    What underlying mechanism primarily leads to hyperprolactinaemia in patients taking antipsychotic drugs?

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

    Study Notes

    Controlled Drugs

    • The Misuse of Drugs Act (1971) restricts the manufacture, supply, and possession of controlled drugs, classifying them into three classes based on harmfulness.
    • Class A includes drugs like heroin, cocaine, and ecstasy.
    • Class B includes cannabis, amphetamines, and barbiturates.
    • Class C includes some benzodiazepines, anabolic steroids, and tramadol.
    • The Misuse of Drugs Regulations (2001) outline the requirements for authorized persons to supply and possess controlled drugs.
    • Schedule 1 controlled drugs (e.g., LSD, ecstasy) are not used medicinally and require a Home Office license.
    • Schedule 2 includes opioids, stimulants, and certain cannabis-based products.
    • Schedule 3 includes barbiturates, benzodiazepines, and some analgesics.
    • Schedule 4 includes drugs subject to minimal control, such as benzodiazepines and non-benzodiazepine hypnotics.
    • Schedule 5 includes preparations of controlled drugs with low strength and are mostly exempt from controlled drug regulations.
    • Controlled drug prescriptions must be indelible, signed, dated, and include the prescriber's UK address.
    • A pharmacist cannot dispense a controlled drug unless all required information is on the prescription.
    • In the case of Schedule 2 or 3 drugs, a pharmacist can amend the prescription with minor typographical errors.
    • The maximum quantity of Schedule 2, 3, or 4 controlled drugs prescribed should not exceed 30 days, but exceptions are allowed.
    • Controlled drug prescriptions are valid for specific periods: 28 days for Schedules 2, 3, and 4; 6 months for Schedule 5.
    • Prescriptions for Schedule 2 or 3 controlled drugs can be dispensed in installments.
    • Repeatable prescriptions are allowed for Schedule 4 and 5 controlled drugs.
    • The security of prescription forms is crucial, with prescribers responsible for safekeeping them.

    Prescribing Controlled Drugs

    • Prescriptions for controlled drugs should be stamped with the pharmacy stamp and endorsed by the pharmacist.
    • Drugs associated with dependence require cautious prescribing with a written management plan and regular reviews.
    • Avoid abrupt discontinuation of dependence-associated drugs and implement a withdrawal or dose reduction schedule.
    • The NICE guideline on dependence and withdrawal management provides further advice.

    Drug Addiction

    • The most common drugs of addiction are crack cocaine and opioids (especially heroin).
    • Medical practitioners with a Home Office Special Licence can prescribe heroin and other Schedule 1 controlled drugs for addicts.
    • Cannabis cannot be prescribed for medicinal use.
    • Individuals prescribed opioid substitution therapy (e.g., methadone) can take their daily dose under supervision.
    • Doctors providing structured drug treatment for substance dependence should report cases to relevant systems.

    Dementia

    • Dementia is a progressive syndrome characterized by cognitive and behavioral symptoms.
    • Alzheimer's disease is the most common type, followed by vascular dementia, dementia with Lewy bodies, and frontotemporal dementia.
    • Treatment aims to promote independence, maintain function, and manage symptoms.
    • Non-drug treatment options include cognitive stimulation programs, reminiscence therapy, and occupational therapy.
    • Drug treatment should only be initiated under specialist advice.
    • Donepezil, galantamine, and rivastigmine (acetylcholinesterase inhibitors) are first-line treatments for mild-to-moderate Alzheimer's disease.
    • Memantine hydrochloride is an alternative for patients who cannot tolerate acetylcholinesterase inhibitors.
    • Non-Alzheimer's dementia patients may benefit from certain acetylcholinesterase inhibitors and memantine.
    • Antipsychotic drugs should be used with caution and at the lowest effective dose.
    • Psychological treatments, like CBT, can be considered for patients with mild to moderate depression or anxiety.
    • Non-drug approaches should be considered for sleep problems and insomnia.

    Medications for Dementia

    • Donepezil inhibits acetylcholinesterase and is used to treat mild to moderate dementia in Alzheimer's disease.
    • Caution is advised in patients with asthma, COPD, and heart conditions.
    • Possible side effects of donepezil include nausea, dizziness, and diarrhea.
    • Dosage should be started low and increased gradually.
    • Acetylcholinesterase is another cholinesterase inhibitor used for dementia treatment.
    • It is available in immediate-release and modified-release forms.
    • Galantamine is a non-proprietary acetylcholine inhibitor available in oral solution and modified-release capsules.
    • Rivastigmine is a reversible noncompetitive inhibitor of acetylcholinesterases used for mild to moderate dementia in Alzheimer's disease and Parkinson's disease.
    • It is available in oral and transdermal forms.
    • Rivastigmine can be used to treat mild-to-moderate dementia in Alzheimer's disease and Parkinson's disease.
    • It is available in oral capsules and transdermal patches.
    • Dosage should be increased gradually according to response and tolerance.

    Epilepsy Control

    • Epilepsy control aims to prevent seizures using antiepileptic drugs.
    • Dosage should be adjusted carefully, starting low and increasing gradually to control seizures.
    • Consider factors like seizure type, epilepsy syndrome, age, sex, and comorbidities when choosing medication.
    • Most antiepileptic drugs can be given twice daily, but some may need more frequent dosing to avoid adverse effects.
    • Monotherapy is preferred, but combination therapy may be necessary when monotherapy fails.
    • Refer patients for appropriate treatment if mood changes, distressing thoughts, or suicidal feelings occur.
    • Antiepileptic drugs have been divided into three risk-based categories to help healthcare professionals ensure continuity of supply for specific manufacturers' products.

    Antiepileptic Hypersensitivity Syndrome

    • It is a rare but potentially fatal syndrome associated with some antiepileptic drugs.
    • Usually starts within 1 to 8 weeks of exposure.
    • Symptoms include fever, rash, lymphadenopathy, liver dysfunction, and multi-organ failure.
    • Immediately withdraw the drug and seek expert advice if symptoms occur

    Epilepsy Treatment Withdrawal

    • Consider withdrawal of antiepileptic drugs in seizure-free patients after at least two years.
    • Assess the risk of seizure recurrence before discontinuing treatment.
    • Withdraw only one drug at a time and reduce dosage gradually over at least three months.
    • Reverse the last dose reduction and seek guidance from an epilepsy specialist if seizures recur during or after discontinuation.

    Epilepsy and Driving

    • If a driver has a seizure, they must stop driving immediately and inform the DVLA.
    • Patients with established epilepsy may drive if they are not a danger to the public and are compliant with treatment.
    • To continue driving, patients must be seizure-free for at least one year or have a pattern of seizures established for one year without influence on their consciousness or ability to act.
    • Those who have had a seizure while asleep are not permitted to drive for one year from the date of each seizure, unless a history or pattern of sleep seizures occurring solely during sleep has been established for at least one year.

    Epilepsy and Pregnancy

    • Pregnancy is a significant risk associated with antiepileptic drugs, particularly valproate.
    • Valproate must not be used for females of childbearing potential unless alternative treatments are ineffective or not tolerated, and the Pregnancy Prevention Programme conditions are met.
    • Consider lamotrigine and levetiracetam as safer options based on available evidence.
    • Discuss the risks associated with antiepileptic drugs and untreated epilepsy during pregnancy with female patients.
    • Female patients should not discontinue treatment without consulting their doctor.

    Epilepsy and Breastfeeding

    • Breastfeeding is generally encouraged for females taking antiepileptic monotherapy, but close monitoring is recommended for combination therapy or risk factors like premature birth.
    • Infants should be monitored for sedation, feeding difficulties, weight gain, and developmental milestones.

    Epilepsy Seizure Types

    • Focal seizures with or without secondary generalisation can be treated with lamotrigine or levetiracetam as first-line options.
    • Generalised tonic-clonic seizures can be treated with sodium valproate as first-line monotherapy.
    • Absence seizures can be treated with ethosuximide as first-line treatment.
    • Myoclonic seizures can be treated with sodium valproate as first-line treatment for males and females unable to have children.
    • Atonic or tonic seizures are typically in childhood, in specific epilepsy syndromes, or associated with cerebral damage or learning disabilities.

    Epilepsy Syndromes

    • Patients with an epilepsy syndrome that is likely to be drug-resistant should be referred to a tertiary epilepsy service.
    • For Dravet syndrome, a neurologist with expertise in epilepsy should be involved in treatment decisions.
    • Patients with Lennox-Gastaut syndrome may have their seizures exacerbated if treated with specific antiepileptic drugs.

    Seizure Emergencies

    • Repeated or cluster seizures, prolonged convulsive seizures, and convulsive status epilepticus should be managed as a medical emergency.
    • If an emergency management plan is not available, treatment with a benzodiazepine should be urgently considered for patients with repeated or cluster seizures, or prolonged convulsive seizures.
    • For convulsive status epilepticus, immediate measures include positioning the patient to avoid injury, supporting respiration, maintaining blood pressure, and correcting hypoglycaemia.
    • If no response to the first dose of a benzodiazepine is found, seek emergency services or expert advice.
    • The urgency to treat non-convulsive status epilepticus depends on the severity of the patient's condition.
    • Febrile convulsions need no specific treatment, but prolonged or recurrent febrile convulsions must be actively treated.

    Epilepsy Medications

    • Briviact (UCB Pharma Ltd) is prescribed for focal seizures with or without secondary generalization.
    • It can be administered orally, intravenously, or intrathecally.

    Briviact (Briviact®)

    • Briviact is used to treat seizures associated with Lennox-Gastaut syndrome and Dravet syndrome.
    • Adults should take 25-50 mg twice daily, adjusted according to response, and maintain 25-100 mg twice daily.
    • Side effects include anxiety, appetite decreased, constipation, cough, depression, dizziness, drowsiness, fatigue, increased risk of infection, insomnia, irritability, nausea, vertigo, and vomiting.
    • The nervous system may also experience abnormal behavior, neutropenia, psychotic disorder, and suicidal behaviors.
    • Pregnancy is advised to avoid unless potential benefit outweighs the risk.
    • Breast feeding is advised to avoid.
    • Hepatic impairment is advised due to the risk of increased exposure.

    Cannabidiol

    • Cannabidiol is used for treating seizures associated with Lennox-Gastaut syndrome and Dravet syndrome.
    • The maximum dose is 2.5 mg/kg twice daily for 1 week.
    • It is recommended for adults to take the medication at the same time with respect to food.
    • The medication is also used for seizures associated with tuberous sclerosis complex.
    • Pregnancy is advised to avoid unless potential benefit outweighs the risk.
    • Breast feeding is advised to avoid.
    • Hepatic impairment is advised with caution.
    • Dose adjustments are advised.
    • Monitoring requirements include monitoring liver function at baseline, at 1 month, 3 months, and 6 months of treatment, then periodically thereafter.

    Carbamazepine

    • Carbamazepine is a medication used to treat epilepsy and other seizure disorders.
    • Adults should start with 100-200 mg once a day, gradually increasing to 0.8-1.2 g daily in divided doses.
    • Elderly patients should reduce the initial dose.
    • Side effects include headache, ataxia, drowsiness, nausea, vomiting, blurring of vision, dizziness, and allergic skin reactions.
    • Pregnancy is an increased risk of major congenital malformations with carbamazepine.
    • Breast feeding is advised against.

    Cenobamate

    • Cenobamate is an adjunctive treatment for focal seizures with or without secondary generalization.
    • It is prescribed by mouth and gradually increased in steps.
    • The usual target dose is 200 mg once daily.
    • Side effects include confusion, constipation, diarrhea, dizziness, drowsiness, dry mouth, fatigue, gait abnormality, headache, hyperomnia, irritability, memory impairment, movement disorders, nausea, nystagmus, skin reactions, speech impairment, vertigo, vision disorders, vomiting, rare or very rare drug reaction with eosinophilia and systemic symptoms (DRESS), and suicidal behaviors.
    • Pregnancy is advised to avoid unless potential benefit outweighs risk.
    • Breast feeding is advised to avoid.
    • Hepatic impairment is advised to avoid in mild or moderate impairment.
    • Renal impairment is advised to avoid in end-stage renal disease or haemodialysis patients.

    Eslicarbazepine

    • Eslicarbazepine (Zebinix) is used for the treatment of focal seizures in adults and elderly patients.
    • It is recommended to start with 400 mg once daily for 1-2 weeks, then increase to 800 mg once daily, and if necessary, to 1.2 g once daily (max. per dose 1.6 g).
    • Side effects include appetite decreased, asthenia, concentration impaired, diarrhea, dizziness, drowsiness, electrolyte imbalance, gait abnormal, headaches, movement disorders, nausea, skin reactions, sleep disorders, vertigo, vision disorders, vomiting, alopecia, anaemia, anxiety, bradycardia, chest pain, chills, confusion, constipation, depression, dry mouth, eye disorders, flushing, gastritis, gastrointestinal discomfort, haemorrhage, hearing, and other neurologic disorders.
    • Pregnancy is advised to avoid.
    • Breast feeding is advised to avoid, except with prescriber approval.

    Ethosuximide

    • Ethosuximide is used to treat seizures, atypical absence seizures, and myoclonic seizures.
    • For children aged 1-5 years, the dosage is 5 mg/kg twice daily, increasing every 5-7 days.
    • For children aged 6-17 years, the dosage is 250 mg twice daily, then increased in steps of 250 mg every 5-7 days.
    • Adults are advised to take 500 mg daily in two divided doses, then increased in steps of 250 mg every 5-7 days.
    • Side effects include aggression, agranulocytosis, decreased appetite, blood disorder, bone marrow disorders, concentration impaired, depression, diarrhea, dizziness, drowsiness, erythema nodosum, fatigue, gastrointestinal discomfort, generalised tonic-clonic seizure, headache, hiccups, leucopenia, libido increased, lupus-like syndrome, mood altered, movement disorders, nausea, nephrotic syndrome, oral disorders, psychosis, rash, sleep disorders, Stevens-Johnson syndrome, suicidal behaviors, vaginal haemorrhage, vision disorders, vomiting, and weight decreased.
    • Pregnancy is a significant risk factor.
    • Breast feeding is advised to avoid.
    • Hepatic and renal impairment is advised with caution.

    Fenfluramine

    • Fenfluramine is a serotonin-releasing agent that stimulates multiple 5-HT receptor subtypes in the brain.
    • It is recommended for the treatment of seizures associated with Dravet syndrome (specialist use only).
    • Contra-indications include pulmonary arterial hypertension, valvular heart disease, and certain conditions such as anorexia nervosa and bulimia nervosa.
    • Side effects include decreased appetite, abnormal behavior, constipation, diarrhea, drowsiness, fall, fatigue, fever, increased risk of infection, irritability, status epilepticus, tremor, vomiting, weight decrease, angle closure glaucoma, mydriasis.
    • Pregnancy is advised to avoid.
    • Breast feeding is advised to avoid.
    • Gastrointestinal impairment is advised with caution.
    • Monitoring requirements include an echocardiogram before starting treatment, every 6 months for the first 2 years, and annually thereafter.

    Fosphenytoin Sodium

    • Fosphenytoin sodium is a pro-drug of phenytoin and is used for treating seizures associated with neurosurgery or head injury.
    • Adults should start with 20 mg(PE)/kg, then 4–5 mg(PE)/kg daily in divided doses.
    • Elderly patients should consider a 10-25% reduction in dose or infusion rate.
    • Temporary substitution for oral phenytoin therapy is also recommended.

    Fenfluramine

    • Medication used for treating seizures associated with Dravet syndrome
    • Potential side effects include decreased appetite, abnormal behavior, constipation, diarrhea, drowsiness, fall, fatigue, fever, increased risk of infection, irritability, and seizure activity
    • Follow controlled access program and consult product literature for more information

    Phenytoin Sodium

    • Manufacturer issued new guideline based on MHRA/CHM guidelines
    • Focus on monitoring doses and contraindications, potential risks during pregnancy
    • Associated with severe cardiovascular reactions (asystole, ventricular fibrillation, cardiac arrest)
    • Monitor heart rate, blood pressure, and respiratory function during infusion
    • Observe patient for at least 30 minutes after infusion
    • Reduce infusion rate or discontinue if hypotension occurs
    • Other potential side effects include acute psychosis, agranulocytosis, appetite disorder, atrial conduction depression, atrioventricular block, bone disorders, bone fracture, bone marrow disorders, bradycardia, cardiotoxicity, cerebrovascular insufficiency, and circulatory collapse

    Fosphenytoin

    • Associated with cross-sensitivity, reported with carbamazepine
    • Pregnancy increases risk of major congenital malformations and adverse effects on neurodevelopment
    • Manufacturer advises caution in monitoring plasma-protein binding changes during pregnancy
    • Small amounts present in breast milk are not known to be harmful
    • Monitor hepatic impairment or hypoalbuminaemia and hyperbilirubinaemia, consider 10-25% reduction in dose or infusion rate
    • Monitor renal impairment or hypoalbuminaemia, consider 10-25% reduction in dose or infusion rate
    • Avoid pre-treatment screening for the HLA-B* 1502 allele in individuals of Han Chinese or Thai origin unless essential due to an increased risk of Stevens-Johnson syndrome

    Gabapentin

    • Used for adjunctive treatment of focal seizures with or without secondary generalization
    • For children aged 6-11 years, recommended dosage is 10 mg/kg once daily, then 10 mg/kg twice daily, then 10 mg/kg three times a day.
    • Usual dose is 25-35 mg/kg daily in three divided doses
    • For children aged 12-17 years, recommended dosage is 300 mg once daily, then 300 mg twice daily on day 2, then 300 mg three times a day on day 3, or 300 mg three times a day on day 1, then increased in steps of 300 mg every 2-3 days in three divided doses
    • Monotherapy for focal seizures with or without secondary generalization is recommended for children aged 12-17 years with the same dosage as adjunctive treatment
    • Also used for menopausal symptoms, oscillopsia in multiple sclerosis, spasticity in multiple sclerosis, and muscular symptoms in motor neurone disease
    • In adults, recommended dosage is 300 mg once daily for 1-2 weeks, then 300 mg twice daily for 1-2 weeks, then 300 mg three times a day for 1-2 weeks, or 100 mg three times a day, then increased in steps of 100 mg three times a day, every 1–2 weeks, adjusted according to response
    • Unlicensed use of gabapentin is not allowed in children under 12 years old
    • Not licensed for the treatment of menopausal symptoms, oscillopsia in multiple sclerosis, spasticity in multiple sclerosis, or muscular symptoms in motor neurone disease
    • Levels of propylene glycol, acesulfame K, and saccharin sodium in gabapentin oral solution may exceed WHO recommended daily intake limits if given to adolescents or adults with low body weight
    • Rare risk of severe respiratory depression, even without concomitant opioid medicines
    • Patients with compromised respiratory function, respiratory or neurological disease, renal impairment, concomitant use of central nervous system (CNS) depressants, and elderly people might be at higher risk of experiencing severe respiratory depression
    • Gabapentin has been reclassified as a Class C controlled substance and is now a Schedule 3 drug, but is exempt from safe custody requirements
    • Healthcare professionals should evaluate patients carefully for a history of drug abuse before prescribing gabapentin
    • Observe patients for signs of abuse and dependence
    • Inform patients of the potentially fatal risks of interactions between gabapentin and alcohol, and with other medicines that cause CNS depression, particularly opioids
    • Gabapentin may exacerbate seizures in patients with absence or myoclonic seizures, tonic or atonic seizures, Dravet syndrome, Lennox-Gastaut syndrome, and myoclonic-atonic seizures
    • Common side effects include anxiety, appetite abnormal, arthralgia, asthenia, behavior abnormal, confusion, constipation, cough, depression, diarrhea, dizziness, drowsiness, dry mouth, dysarthria, dyspnoea, emotional instability, fever, flatulence, gait abnormal, gastrointestinal discomfort, headache, hypertension, increased risk of infection, insomnia, leucopenia, malaise, memory loss, movement disorders, muscle complaints, nausea, nystagmus, oedema, pain, reflexes abnormal, sensation abnormal, sexual dysfunction, skin reactions, thinking abnormal, tooth disorder, tremor, vasodilation, vertigo, visual impairment, vomiting, uncommon cognitive impairment, dysphagia, palpitations, rare or very rare respiratory depression
    • Monitor for signs of gabapentin abuse, as it can cause false positive readings with some urinary protein tests
    • Follow expert advice on opening capsules and masking the bitter taste

    Lacosamide

    • Available in various forms, including infusion vials, tablets, and monotherapy of focal seizures with valproate
    • Recommended as an adjunctive therapy for partial-onset seizures with or without secondary generalization in adolescents and children with epilepsy
    • Contraindications include second- or third-degree AV block, conduction problems, elderly patients, risk of PR interval prolongation, seizures, and severe cardiac disease
    • May exacerbate seizures in patients with Dravet syndrome and Lennox-Gastaut syndrome
    • Common side effects include asthma, cognitive disorders, concentration impaired, confusion, constipation, depression, diarrhea, dizziness, drowsiness, dry mouth, dysarthria, dyspepsia, feeling drunk, flatulence, gait abnormality, headache, insomnia, memory impairment, mood altered, movement disorders, muscle spasms, myoclonic seizure, nausea, nystagmus, sensation abnormal, skin reactions, tinnitus, tremor, vertigo, vision disorders, vomiting, agitation, angioedema, arrhythmias, atrioventricular block, behavior abnormal, hallucination, psychotic disorder, suicidal behaviors, syncope
    • Pregnancy should be avoided unless potential benefit outweighs risk, as it is embryotoxic in animal studies
    • Exercise caution for epinephrine impairment and adjust dose for renal impairment
    • For intermittent intravenous infusion, undiluted or dilute with glucose 5%, sodium chloride 0.9%, or Lactate Ringer’s Solution; give over 15-60 minutes, or give doses greater than 200 mg over at least 30 minutes
    • Counsel patients and careers on symptoms of cardiac arrhythmia and advise to seek immediate medical advice if these occur
    • If a dose is more than 6 hours late, do not take the missed dose and take the next dose at the normal time
    • Counsel patients and carers on the effects on driving and performing skilled tasks, as they may experience increased risk of dizziness and blurred vision

    Lamotrigine

    • Medication used to treat bipolar disorder and epilepsy
    • Provides a comprehensive overview of the various treatments for seizures, including those induced by enzyme-inducing drugs and those not
    • Discusses the different types of seizures, their duration, and the dosages required for each type
    • Advise dose titration and dose titration when restarting after an interval of more than 5 days
    • For adults: Initially 25 mg once daily on alternate days for 14 days, then increased in steps of up to 50 mg every 7-14 days. Maintenance is 100-200 mg daily in 1–2 divided doses, and dose titration should be repeated if restarting after an interval of more than 5 days.
    • For children aged 2-11 years: Initially 300 micrograms/kg twice daily for 14 days, then 600 micrograms/kg twice daily for further 14 days. The dosage is then increased in steps of up to 1.2 mg/kg every 7-14 days. Maintenance is 5-15 mg/kg daily in 1–2 divided doses, and dose titration should be repeated if restarting after an interval of more than 5 days.
    • For children aged 12-17 years: Initially 50 mg once daily for 14 days, then 50 mg twice daily for further 14 days. The dosage is then increased in steps of up to 100 mg every 7–14 days. Maintenance is 200-400 mg daily in 2 divided doses, increased if necessary up to 700 mg daily.
    • For monotherapy or adjunctive therapy of bipolar disorder: Initially 25 mg once daily for 14 days, then 50 mg daily in 1–2 divided doses for further 14 days. Maintenance is 200 mg daily in 1–2 divided doses. Dose adjustments may be required if other drugs are added or withdrawn from their treatment regimens. Dose titration should be repeated if restarting after an interval of more than 5 days.

    Lamotrigine

    • Prescribed twice daily
    • Dose adjustments may be required if other drugs are added or withdrawn.
    • Patients stabilized on lamotrigine may experience common and very common side effects such as aggression, agitation, arthralgia, diarrhea, dizziness, drowsiness, dry mouth, fatigue, headache, irritability, nausea, pain, rash, sleep disorders, tremor, vomiting, alopecia, movement disorders, and vision disorders.
    • Rare or very rare side effects include confusion, conjunctivitis, disseminated intravascular coagulation, face edema, fever, haemophagocytic lymphohistiocytosis, and hallucination.
    • May exacerbate seizures in patients with myoclonic seizures (including juvenile myoclonic epilepsy), Dravet syndrome, and Lennox-Gastaut syndrome.
    • Serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, have developed, especially in children.
    • Rash is sometimes associated with a hypersensitivity syndrome and is more common in patients with a history of allergy or rash from other antiepileptic drugs.
    • Consider withdrawal if rash or signs of hypersensitivity syndrome develop.
    • Factors associated with increased risk of serious skin reactions include concomitant use of valproate, initial lamotrigine dosing higher than recommended, and more rapid dose escalation than recommended.
    • During pregnancy, plasma-drug concentration should be monitored before, during, and after pregnancy, including shortly after birth, and doses adjusted according to response.
    • Lamotrigine is present in breast milk, but limited data suggest no harmful effect on infants.
    • Patients and carers should be alert for skin reactions, blood disorders, and bone-marrow failure symptoms.
    • Lamotrigine can be prescribed in various forms, including oral suspension, oral solution, and disposable tablets.

    Lamotrigine, Lamictal, and Levetiracetam

    • Lamotrigine is a non-proprietary medication used for monotherapy of focal seizures with or without secondary generalization.
    • For children aged 16-17 years, start with 250 mg once daily for 1 week, then increase to 250 mg twice daily, then increase in steps of 250 mg twice daily, adjusting according to response (maximum dose: 1.5 g twice daily). Increase the dose every two weeks.
    • For adjunctive therapy of focal seizures with or without secondary generalization, children aged 1-5 months should start with 7 mg/kg once daily, then increase in steps of up to 7 mg/kg twice daily.
    • For children aged 6 months-17 years, start with 10 mg/kg once daily, then increase in steps of up to 10 mg/kg twice daily (maximum dose: 30 mg/kg twice daily), adjusting the dose every two weeks.
    • For myoclonic seizures and tonic-clonic seizures, start with 10 mg/kg once daily, then increase in steps of up to 10 mg/kg twice daily (maximum dose: 30 mg/kg twice daily), adjusting the dose every two weeks.
    • For children aged 12-17 years (body-weight 50 kg and above), start with 250 mg twice daily, then increase in steps of 500 mg twice daily (maximum dose: 1.5 g twice daily), adjusting the dose every two to four weeks.
    • Convulsive status epilepticus (administered on expert advice) is also advised for intravenous injection.
    • For children aged 4-17 years (body-weight up to 50 kg), start with 10 mg/kg once daily, then increase in steps of up to 10 mg/kg twice daily (maximum dose: 30 mg/kg twice daily), increasing the dose every two weeks.

    Levetiracetam

    • A medication used for treating convulsive status epilepticus, but it is not licensed for this indication.
    • Not recommended for use in children under 6 years, those with body weight less than 25 kg, or for administering doses below 250 mg.
    • The manufacturer advises using oral solutions for children under 6 years, those with body weight less than 25 kg, or for administering doses below 250 mg.
    • The manufacturer also warns against switching between different manufacturers' products and discussing antiepileptic drugs in pregnancy.
    • Risk factors for QT interval prolongation include anxiety, appetite decreased, asthenia, abnormal behavior, cough, depression, diarrhea, dizziness, drowsiness, gastrointestinal discomfort, headache, increased risk of infection, insomnia, mood altered, movement disorders, nausea, skin reactions, tremor, vertigo, vomiting, alopecia, concentration impaired, confusion, hallucination, leucopenia, memory impairment, muscle weakness, myalgia, paraesthesia, psychotic disorder, suicidal behaviors, thrombocytopenia, vision disorders, weight changes, acute kidney injury, agranulocytosis, bone marrow disorders, delirium, encephalopathy, gait abnormal, hepatic disorders, hyponatraemia, neutropenia, pancreatitis, personality disorder, QT interval prolongation, rhabdomyolysis, seizures exacerbated, severe cutaneous adverse reactions (SCARs), thinking abnormal, and frequency not known Neuroleptic malignant syndrome.
    • Pregnancy is a critical period for monitoring clinical response, as plasma concentrations decrease during pregnancy.
    • The manufacturer advises caution in severe impairment and recommends maintenance dose reduction of 50% in severe impairment if creatinine clearance is less than 60 mL/minute/1.73m2.
    • In adults, the maximum daily dose is 2 g if eGFR is 50-80 mL/minute/1.73m2, 1.5 g if eGFR is 30-50 mL/minute/1.73m2, and 1 g daily if eGFR is less than 30 mL/minute/1.73m2.

    Levetiracetam (Intravenous Use)

    • Used for focal seizures, myoclonic seizures, or tonic-clonic seizures and for convulsive status epilepticus in children.
    • The dose should be diluted with glucose 5% or sodium chloride 0.9% and given over 15 minutes.
    • If switching between oral therapy and intravenous therapy, the intravenous dose should be the same as the established oral dose.
    • Patients and caregivers should seek medical advice if signs of depression or suicidal ideation emerge, and consult their doctor immediately if seizures worsen.
    • The Medicines for Children leaflet provides information on the effects of Levetiracetam on driving and performing skilled tasks, including increased risk of somnolence or other CNS side-effects.
    • Medicinal forms available from special-order manufacturers include oral solution, granules, tablets, tablets, and electrolytes.
    • Infusion solutions are available in a 100 mg per 1 ml concentration for solution for infusion vials (Levetiracetam (Non-proprietary) and Keppra (UCB Pharma Ltd)).
    • Oral solution is available in various sizes, with the most common being 100 mg per 1 ml.

    Oxcarbazepine

    • Available in various forms, such as tablets, tablets, and capsules.
    • Patients should be aware of the potential side-effects of Levetiracetam on their brain and spinal cord, and should consult their doctor if they experience any adverse reactions.
    • Monotherapy for the treatment of focal seizures with or without secondary generalised tonic-clonic seizures is recommended for children aged 6-17 years, starting at 4-5 mg/kg twice daily.
    • Adjunctive therapy is also available for adults, starting at 300 mg twice daily and increasing in steps to 600 mg daily.
    • The usual dose is 0.6–2.4 g daily in divided doses.
    • In adjunctive therapy, the dose of concomitant antiepileptics may need to be reduced when using high doses of oxcarbazepine.
    • It is not licensed for the treatment of primary generalised tonic-clonic seizures.
    • important safety information is provided in the MHRA/CHM guideline on antiepileptic drugs, including the risk of suicidal thoughts and behavior, and the use of antiepileptic drugs in pregnancy.
    • Cautions include the presence of HLA-B1502 or HLA-A3101 allele, which is strongly associated with an increased risk of carbamazepine-induced Stevens-Johnson syndrome and may also occur with oxcarbazepine, a structurally-related antiepileptic.
    • The presence of HLA-A*3101 allele, particularly in individuals of European or Japanese origin, is associated with an increased risk of carbamazepine-induced cutaneous adverse reactions.
    • Oxcarbazepine may exacerbate seizures in patients with absence or myoclonic seizures, tonic or atonic seizures, Dravet syndrome, Lennox-Gastaut syndrome, and myoclonic-atonic seizures.
    • Side effects include abdominal pain, agitation, alopecia, asthenia, ataxia, concentration impaired, diarrhea, dizziness, depression, emotional lability, headache, hyponatraemia, nausea, nystagmus, skin reactions, vertigo, vision disorders, vomiting, uncommon leucopenia, rare or very rare angioedema, arrhythmia, atrioventricular block, hepatitis, hypothyroidism, pancreatitis, severe cutaneous adverse reactions (SCARs), systemic lupus erythematosus (SLE), thrombocytopenia, frequency not known, granulocytosis, bone disorders, bone marrow disorders, hypertension, inappropriate antidiuretic hormone secretion like-syndrome, neutropenia, speech impairment, suicidal behaviors, allergy and cross-sensitivity, and hypersensitivity to carbamazepine.
    • Pregnancy is a critical period for monitoring clinical response and plasma concentration monitoring of the active metabolite.
    • Breast feeding is probably too small to be harmful but manufacturer advises avoid.
    • Manufacturer advises caution in severe impairment.
    • Renal impairment should be considered, with initial doses reduced if creatinine clearance is less than 30 mL/minute and increased according to response at intervals of at least 1 week.
    • Pre-treatment screening includes testing for the HLA-B*1502 allele in individuals of Han Chinese or Thai origin, and considering testing in other at-risk Asian populations such as Filipino or Malaysian origin.

    Oxcarbazepine (Monitoring)

    • Monitor plasma-sodium concentration in patients at risk of hyponatraemia and body-weight in patients with heart failure.
    • Patients may need to be maintained on a specific manufacturer's branded or generic oxcarbazepine product, and switching between formulations should be taken care of.
    • The need for continued supply of a particular manufacturer's product should be based on clinical judgement and consultation with the patient or their carer, taking into account factors such as seizure frequency and treatment history.
    • Patients or their carers should be told how to recognize signs of blood, liver, or skin disorders and advised to seek immediate medical attention if symptoms such as lethargy, confusion, muscular twitching, fever, rash, blistering, mouth ulcers, bruising, or bleeding develop.

    Oxcarbazepine (Medicines for Children)

    • Oxcarbazepine is available for preventing seizures.
    • There can be variation in the licensing of different medicines containing the same drug.
    • Forms available from special-order manufacturers include oral suspension, tablets, and tablets.

    Oxcarbazepine (Dosing)

    • The indications and dose for adjunctive treatment of focal seizures with or without secondary generalised seizures are as follows: for children 4-11 years (body-weight up to 20 kg), 1 mg once daily, then increased in steps of 1 mg at intervals of at least every 2 weeks, adjusted according to response; maintenance 2-4 mg once daily, then increased in steps of 0.5 mg at intervals of at least every 2 weeks; maximum 6 mg per day; for children 4-11 years (body-weight 20-29 kg): initial 1 mg once daily, dose to be taken before bedtime, then increased in steps of 1 mg at intervals of at least every 2 weeks; and for children 4-11 years (body-weight 30 kg and above): initial 2 mg once daily, dose to be taken before bedtime, then increased in steps of 2 mg at intervals of at least every 2 weeks; maximum 12 mg per day.
    • The medication is prescribed for children aged 12-17 years, with a daily dose of 2 mg taken before bedtime. If tolerated, the dose can be increased in steps of 2 mg at intervals of at least every two weeks, with maintenance of 4-8 mg once daily. The maximum dosage is 12 mg per day.
    • For adults, the dosage should be 2 mg once daily, with maintenance of 4-8 mg once daily.
    • Adjunctive treatment of primary generalised tonic-clonic seizures is also available.
    • For children 7-11 years (body-weight up to 20 kg), the dosage should be 1 mg once daily, with maintenance of 2-4 mg once daily. If tolerated, the dosage can be increased in steps of 0.5 mg at intervals of at least every 2 weeks, adjusted according to response.
    • For children 7-11 years (body-weight 20-29 kg), the dosage should be 1 mg once daily, with maintenance of 4-6 mg once daily.
    • For children 30 kg and above, the dosage should be 2 mg once daily, with maintenance of 4-8 mg once daily.

    Antiepileptic Drugs

    • Antiepileptic drugs have side effects such as anxiety, appetite abnormality, back pain, behavior abnormality, confusion, dizziness, drowsiness, dysarthria, fatigue, gait abnormality, irritability, movement disorders, nausea, vertigo, vision disorders, weight increased, uncommon suicidal behaviors, frequency not known, homicidal ideation, and severe cutaneous adverse reactions (SCARs).
    • Pregnancy should be avoided due to their embryotoxicity in animal studies, and breastfeeding should be avoided due to its presence in milk.
    • Antiepileptic drugs should be used cautiously in mild to moderate impairments and severe impairments.

    Perampanel

    • A medication used for the adjunctive treatment of partial-onset seizures in patients with epilepsy aged 12 years and older.
    • It is recommended to use a maximum dosage of 8mg per day in mild to moderate impairment, and avoid it in moderate or severe impairment.
    • The manufacturer advises patients and caregivers on the effects on driving and performing skilled tasks, as there is an increased risk of dizziness and drowsiness.
    • National funding/access decisions have been made by the Scottish Medicines Consortium (SMC) and the All Wales Medicines Strategy Group (AWMSG).
    • The manufacturer also offers oral suspension and tablets, with some exceptions, such as Sorbitol.
    • Medicinal forms available from special-order manufacturers include oral suspension, tablets, and tablets.

    Phenytoin

    • The dosage for tonic-clonic seizures and focal seizures can be adjusted according to the patient's response to the medication.
    • For prevention and treatment of seizures during or following neurosurgery or severe head injury, the dosage should be adjusted according to plasma-phenytoin concentration.
    • Status epilepticus is a condition where acute symptomatic seizures associated with head trauma or neurosurgery are initially initiated by slow intravenous injection or intravenous infusion.
    • The loading dose for children 1 month-11 years is 20 mg/kg, followed by 2.5-5 mg/kg twice daily.
    • For children 12-17 years, the dosage is 20 mg/kg, followed by up to 100 mg 3-4 times a day.
    • For adults, the dosage is 20 mg/kg, followed by maintenance of 100 mg every 6-8 hours.
    • Preparations containing phenytoin sodium are not bioequivalent to those containing phenytoin base, but 100mg of phenytoin sodium is approximately equivalent in therapeutic effect to 92 mg phenytoin base.
    • Care is needed when making changes between formulations and plasma-phenytoin concentration monitoring is recommended.

    Phenytoin

    • Phenytoin has a narrow therapeutic index and a non-linear dose-concentration relationship.
    • Small dose increases can lead to large increases in plasma drug concentration and toxicity.
    • Monitoring plasma drug concentration is crucial for safe dosage adjustment.
    • Intravenous phenytoin use is error-prone and requires careful guidance for safe administration.
    • Contraindications include acute porphyrias, HLA-B*1502 allele presence, seizures, and conditions like heart failure.
    • Intramuscular phenytoin is not recommended due to slow and erratic absorption.
    • HLA-B*1502 allele may increase the risk of Stevens-Johnson syndrome.
    • Phenytoin can exacerbate seizures in specific seizure types.
    • Numerous interactions with phenytoin exist, including potential side effects like granulocytosis, bone disorders, and severe cutaneous adverse reactions (SCARs).
    • Overdose symptoms include nystagmus, diplopia, slurred speech, ataxia, confusion, and hyperglycemia.
    • Cross-sensitivity with carbamazepine and antiepileptic hypersensitivity syndrome are reported.
    • Pregnancy increases the risk of congenital malformations and neurodevelopmental problems.
    • Breastfeeding exposes infants to small, likely harmless amounts of the drug.
    • Hepatic impairment increases the risk of accumulation and toxicity due to decreased protein binding.
    • Dose adjustments are advised for both oral and intravenous use in patients with hepatic impairment.
    • The usual therapeutic plasma phenytoin concentration for adults is 10-20 mg/litre (40-80 micromol/litre).
    • Reduced protein binding in pregnancy, the elderly, and certain diseases requires careful interpretation of plasma concentrations.
    • Neonates and children have reduced protein binding and lower therapeutic plasma concentrations.
    • Intravenous phenytoin administration should be monitored with ECG and blood pressure checks.
    • Each injection or infusion should be preceded and followed by a sodium chloride injection to prevent local venous irritation.
    • Intravenous administration rates vary by age and patient factors.
    • Patient and caregiver advice includes recognizing signs of blood or skin disorders and seeking immediate medical attention.

    Pregabalin

    • Pregabalin is a medication used for various conditions, including epilepsy, anxiety disorder, and neuropathic pain.
    • It has been reclassified as a Schedule 3 drug due to concerns about abuse.
    • Healthcare professionals should assess patients for a history of drug abuse before prescribing pregabalin and monitor for signs of abuse and dependence.
    • Pregabalin can cause fatal interactions with alcohol and other CNS depressants, particularly opioids.
    • Studies suggest a slightly increased risk of major congenital malformations in the unborn child when taken during the first trimester of pregnancy.
    • Use during pregnancy is advised to be avoided unless clearly necessary and benefits outweigh risks.
    • Severe respiratory depression has been reported, particularly in patients with compromised respiratory function, taking other CNS depressants, or older than 65 years.
    • Patients should seek immediate medical help if they experience breathing difficulties.
    • Pregabalin can exacerbate seizures in patients with specific seizure types.
    • Numerous interactions with other antiepileptics can occur, including common side effects like dizziness, drowsiness, and gastrointestinal disorders.
    • Potential serious side effects include encephalopathy, respiratory depression, and suicidal behaviors.
    • Prescribing information includes indications, dosage information, forms, and availability.

    Rufinamide

    • Rufinamide is a medication used for treating seizures.
    • The MHRA/CHM has updated advice on switching between different manufacturers' products for treating epilepsy.
    • The guideline includes warnings about potential side effects and addresses allergy and cross-sensitivity syndrome.
    • The guideline advises against breastfeeding, hepatic impairment, and dose adjustments.
    • Tablets can be crushed and administered in water.
    • Counselling on antiepileptic hypersensitivity syndrome is advised.

    Valproate

    • Valproate medicines are contraindicated for use in children aged 1 month to 11 years due to high teratogenic risk.
    • Valproate must not be used in women and girls of childbearing potential unless the Pregnancy Prevention Programme conditions are met.
    • Women and girls must be fully informed of the risks and the need to avoid exposure to valproate in pregnancy.
    • GPs must recall women and girls of childbearing potential, confirm specialist review, and ensure contraception use.
    • Specialists must review patients annually under the Pregnancy Prevention Programme.
    • Pharmacists must dispense valproate medicines in whole packs whenever possible and discuss risks in pregnancy with female patients.
    • The MHRA advises healthcare professionals to identify and review female patients on valproate and provide patient information materials.
    • The Royal College of Psychiatrists offers guidance on withdrawing and alternative options for valproate in women of childbearing potential with psychiatric illnesses.
    • The Annual Risk Acknowledgement Form and guidance have been updated for valproate use.
    • Temporary guidance for female patients on valproate during the COVID-19 pandemic has been issued.
    • Antiepileptic drugs in pregnancy have been updated following a comprehensive safety review.
    • Valproate can cause various side effects, including abdominal pain, agitation, alopecia, and severe cutaneous adverse reactions (SCARs).
    • The MHRA advises against using valproate for migraine prophylaxis and bipolar disorder unless there is no suitable alternative treatment.
    • If valproate is used during pregnancy, the lowest effective dose should be prescribed in divided doses or as modified-release tablets.
    • Neonatal bleeding and hepatotoxicity have been reported with valproate use in pregnancy.
    • Breastfeeding exposes infants to valproate, potentially raising the risk of haematological disorders.
    • Hepatic impairment and renal impairment are advised against, and dose adjustments may be considered.
    • Plasma valproate concentrations are not a useful index of efficacy, so routine monitoring is unhelpful.
    • Liver function should be monitored before and during the first 6 months of therapy.

    Valproate

    • Measure full blood count before starting treatment, and before surgery.
    • Avoid abrupt withdrawal and reduce dose gradually over at least 4 weeks if stopping treatment.
    • Intravenous injection should be diluted with glucose 5% or sodium chloride 0.9%.
    • Tablets may be halved but not crushed or chewed.
    • Capsules may be mixed with soft food or drink at room temperature or cold and swallowed immediately.
    • Syrup may be diluted, preferably in Syrup BP, and used within 14 days.
    • The Pregnancy Prevention Programme supports the use of materials provided by the manufacturer, such as the Patient Guide, Guide for Healthcare Professionals, Risk Acknowledgement Form, and patient cards and stickers with warning symbols.
    • The Royal Pharmaceutical Society has also produced a safe supply algorithm.
    • Care should be taken when switching between oral formulations of valproate, considering seizure frequency and treatment history.
    • Patients may need to be maintained on a specific manufacturer's branded or generic product.
    • Patients and caregivers should not stop taking valproate without discussing it with their doctor.
    • Patients and caregivers should be taught how to recognize signs and symptoms of blood or liver disorders and seek immediate medical attention if symptoms develop.
    • Pharmacists must ensure female patients have a patient card.

    Valproate products

    • Available in tablets, capsules, granules, and solutions for injection.
    • Epilim Chrono (Sanofi) offers a range of tablets, including 200mg, 300mg, 500mg, and 500mg tablets.
    • Epival CR (Gerot Lannach UK Ltd) offers gastro-resistant tablets.
    • Epilim (Sanofi) also offers crushable tablets.
    • Solutions for injection include sodium valproate powder and solvent for injection vials.
    • Injection ampoules are available in various strengths, such as 100mg, 400mg, or 300mg.
    • Modified-release granules are available in various sizes, such as 50mg, 100mg, 250mg, 500mg, 750mg, and 1000mg.
    • Episenta (Desitin Pharma Ltd) offers sodium valproate 500mg and 1000mg granules.

    Tiagabine

    • An antiepileptic drug used to treat refractory generalised tonic-clonic seizures.
    • It is recommended for use in combination with clobazam and valproate under expert supervision.
    • Doses of up to 50 mg/kg daily in 2–3 divided doses should be continued as long as efficacy is observed.
    • Stiripentol capsules and oral powder sachets are not bioequivalent and should be switched under clinical supervision.
    • Side effects include: agitation, decreased appetite, abnormal behavior, drowsiness, irritability, movement disorders, decreased muscle tone, nausea, neutropenia, sleep disorders, vomiting, decreased weight, diplopia, fatigue, photosensitivity reaction, skin reactions, thrombocytopenia, suicidal behaviors.
    • Antiepileptic hypersensitivity syndrome is theoretically associated with stiripentol.
    • Pregnancy and breast feeding should be considered carefully.
    • The manufacturer advises against hepatic impairment and renal impairment.
    • Monitoring requirements include performing full blood count and liver function tests prior to initiating treatment and every 6 months thereafter.
    • The drug may contain aspartame.
    • Tiagabine is also used for adjunctive treatment for focal seizures that are not adequately controlled by other antiepileptics.

    Tiagabine Dosage

    • Children 12-17 years: Initial dosage is 5-10 mg daily in 1–2 divided doses, increased in steps of 5–10 mg/24 hours every week; maintenance 30–45 mg daily in 2–3 divided doses.
    • Adults: Start with 5-10 mg daily in 1–2 divided doses, increased in steps of 5–10 mg/24 hours every week; maintenance 15–30 mg daily in 2–3 divided doses.

    Topiramate

    • Used for monotherapy of generalized tonic-clonic seizures or focal seizures.
    • Side effects: abdominal pain, abnormal behavior, concentration impairment, depression, diarrhea, dizziness, emotional lability, fatigue, gait abnormality, insomnia, nausea, nervousness, speech disorder, tremor, vision disorders, vomiting, drowsiness, psychosis, skin reactions, delusions, hallucinations, suicidal behaviors.
    • Pregnancy should be avoided unless the potential benefit outweighs the risk.
    • The manufacturer advises caution in mild to moderate impairment and avoid in severe impairment.
    • Dose adjustments are advised, with dose reduction and/or longer dose interval with careful titration in mild to moderate impairment.

    Topiramate Dosage

    • Children 6-17 years: 0.5-1 mg/kg once daily for 1 week, then increased in steps of 250-500 micrograms/kg twice daily, increasing by a maximum of 25mg twice daily at intervals of 1–2 weeks.
    • Adults: 25-50 mg once daily for 1 week, dose to be taken at night, then increased in steps of 25–50 mg every 1–2 weeks, dose to be taken in 2 divided doses.

    Vigabatrin

    • An antiepileptic medication used to treat focal seizures in children aged 1 to 23 months.
    • It is also prescribed for adults with newly diagnosed epilepsy.
    • Not licensed for rectal use.
    • Tablets are not licensed to be crushed and dispersed in liquid.
    • Important safety information includes the risk of suicidal thoughts and behavior, as well as the potential for visual field defects.
    • Visual field testing should be carried out before treatment and at 6-month intervals.
    • Patients and their carers should be warned to report any new visual symptoms that develop.
    • Gradual withdrawal of vigabatrin should be considered.
    • Side effects include: suicidal behaviors, abdominal pain, alopecia, anemia, anxiety, arthralgia, behavior abnormality, depression, dizziness, drowsiness, eye disorders, fatigue, headache, insomnia, memory loss, mood altered, nausea, oedema, paraesthesia, speech disorder, thinking abnormal, tremor, vision disorders, vomiting, weight increase, movement disorders, psychotic disorder, seizure, skin reactions, angioedema, encephalopathy, hallucination, hepatitis, optic neuritis, intramyelinic oedema, muscle tone increased, encephalopathic symptoms.
    • Pregnancy should be avoided unless essential.
    • Breast feeding is advised by manufacturers.
    • Renal impairment should be considered.
    • Monitoring requirements include closely monitoring neurological function, heart rate, and blood pressure.

    Vigabatrin Dosage

    • Children 1 to 23 months: Initially 15-20 mg/kg twice daily, increasing over 2-3 weeks to the usual maintenance dose.
    • Adults: 1 g once daily, or 1 g daily in 2 divided doses, then increased in steps of 500 mg every week, adjusted according to response.

    Zonisamide

    • Used to prevent seizures in children and adolescents.
    • Cautions include elderly individuals, history of eye disorders, low bodyweight or poor appetite, metabolic acidosis, and risk factors for renal stone formation.
    • Important to avoid overheating and ensure adequate hydration.
    • Side effects: alopecia, anxiety, decreased appetite, ataxia, bradyphrenia, concentration impaired, confusion, constipation, depression, diarrhea, dizziness, drowsiness, fatigue, fever, gastrointestinal discomfort, hypersensitivity, influenza-like illness, insomnia, memory loss, mood altered, nausea, nystagmus, paraesthesia, peripheral oedema, psychosis, rash, skin reactions, speech disorder, tremor, urolithiases, vision disorders, vomiting, weight decrease, abnormal behavior abnormal, gallbladder disorders, hallucination, hypokalemia, increased risk of infection, leucopenia, respiratory disorders, seizures, suicidal behaviors, thrombocytopenia, Agranulocytosis, angle closure glaucoma, anhidrosis, bone marrow disorders, coma, dyspnoea, eye pain, heat stroke, hepatocellular injury, leucocytosis, lymphadenopathy, metabolic acidosis, myasthenic syndrome, neuroleptic malignant syndrome, pancreatitis, renal failure, renal tubular acidosis, rhabdomyolysis, severe cutaneous adverse reactions (SCARs), urine abnormal, sudden unexplained death in epilepsy.
    • Women of childbearing potential should use effective contraception during treatment and for one month after the last dose.
    • There is an increased risk of intra-uterine growth restriction in pregnancy.
    • Caution should be taken when switching between oral formulations.

    Zonisamide Dosage

    • Adults: 60-180 mg once daily, with a dose of 20 mg/kg taken at night.
    • Infants: 20 mg/kg, then 2.5-5 mg/kg 1–2 times a day.
    • Children 1 month–11 years: 20 mg/kg, then 2.5–5 mg/kg 1–2 times a day.
    • Children 12-17 years: 20 mg/kg, then 300 mg twice daily.

    Phenobarbital

    • May exacerbate seizures in patients with absence seizures, Dravet syndrome, and Lennox-Gastaut syndrome.
    • Side effects: granulocytosis, anticonvulsant hypersensitivity syndrome, behavior abnormal, bone fracture, cognitive impairment, confusion, depression, drowsiness, folate deficiency, hepatic disorders, memory loss, movement disorders, nystagmus, respiratory depression, severe cutaneous adverse reactions (SCARs), skin reactions, suicidal behaviors.
    • There is an increased risk of major congenital malformations and intra-uterine growth restriction in pregnancy.
    • Possible adverse effects on neurodevelopment.
    • Breast feeding should be avoided if possible.
    • The manufacturer advises caution in mild to moderate impairment and renal impairment.
    • The use of phenobarbital should be done with caution, especially in children and their carers, as it may cause overheating and dehydration.

    Phenobarbital Dosage

    • Treatment should avoid abrupt withdrawal due to dependence with prolonged use.
    • Crushing tablets is allowed for oral use.
    • Diluting injection solutions 1 in 10 with water for injections in adults.
    • Intravenous use in children at a rate not more than 100 mg/minute.
    • Different formulations of oral preparations may vary in bioavailability, so patients should be maintained on a specific manufacturer's product.
    • Patient and caregiver advice includes the Medicines for Children leaflet on phenobarbital for preventing seizures.

    Primidone

    • Primidone is an antiepileptic medication that gets partially converted to phenobarbital, the active form of the drug.
    • It is effective in treating various epilepsy types but not typical absence seizures.
    • Dosage varies by age and is administered orally.
    • Monitoring requirements for primidone include measuring plasma concentrations of phenobarbital and treatment cessation.
    • Primidone exposure during pregnancy has been linked to an increased risk of congenital malformations.
    • Exercise caution in patients with hepatic and renal impairment, and dose adjustments might be necessary.

    Benzodiazepines

    • Benzodiazepines are a class of medications used to treat epilepsy, anxiety, insomnia, and acute panic attacks.
    • Common side effects include decreased appetite, consciousness, constipation, dry mouth, fall, gait unsteadiness, libido loss, movement disorders, muscle spasms, nystagmus, psychotic disorder, respiratory disorder, skin reactions, speech impairment, suicidal behaviors, and weight increase.
    • Avoid benzodiazepine use during breastfeeding as they can pass into breast milk and potentially affect infants.
    • Monitor all infants for sedation, feeding difficulties, adequate weight gain, and developmental milestones.
    • Routine measurement of plasma concentrations is not usually necessary for children, but it may be considered in cases of worsening seizures, status epilepticus, suspected noncompliance, or suspected toxicity.
    • Haematological and biochemical monitoring should be performed only when clinically indicated.
    • Consider switching between oral formulations cautiously in children with epilepsy, taking into account seizure frequency and treatment history.
    • Ensure patients being treated for epilepsy continue on a specific manufacturer's product due to variations in bioavailability between formulations.
    • Do not co-prescribe benzodiazepines with opioids, as they can produce additive CNS depressant effects, increasing the risk of sedation, respiratory depression, coma, and death.

    Clonazepam

    • Clonazepam is an antiepileptic medication used to treat various forms of epilepsy.
    • It is available in oral suspension, oral solutions, and tablets.
    • For treatment of status epilepticus, administer 75-125 mg intravenously as a 2.5% solution.
    • Induction of anesthesia is also possible with a dose of 100-150 mg, given over 10-15 seconds, followed by an additional dose after 0.5-1 minute if required.
    • Use caution and consider dose adjustments in debilitated patients or adults over 65 years.
    • Administration should only be performed by personnel experienced in its use and with adequate training in anaesthesia and airway management.
    • Contraindications include acute porphyrias and myotonic dystrophy.
    • Potential risks include acute circulatory failure, cardiovascular disease, elderly individuals, hypovolemia, and respiratory diseases.

    Thiopental Sodium

    • Thiopental Sodium is used for various purposes, including status epilepticus, induction of anesthesia, and conscious sedation.
    • Its dosage varies based on the desired effect and patient characteristics.
    • It's crucial to monitor sedation, feeding difficulties, weight gain, and developmental milestones in infants exposed to thiopental during breastfeeding.
    • The effects of thiopental sodium often last for up to 24 hours.
    • It can be administered by various routes: intravenous, intramuscular, buccal, and subcutaneous.

    Midazolam

    • Midazolam is a benzodiazepine medication commonly prescribed for seizures in children and adolescents aged 10 to less than 18 years.
    • It has a rapid onset of action and a shorter recovery time compared to other benzodiazepines, with a possible longer recovery in the elderly, patients with low cardiac output, or after repeated dosing.
    • It is available in various forms, including Oromucosal solution, solution for injection, infusion, and solution for infusion.
    • Exercise caution when administering midazolam to individuals with hepatic impairment, as it accumulates in adipose tissue and can prolong sedation.
    • Midazolam is present in breast milk and should be avoided for 24 hours after administration.
    • Consider dose adjustments for parenteral preparations, use with caution in chronic renal failure, and avoid co-administration with other CNS depressants, as it can lead to increased sedation and respiratory depression.
    • Keep flumazenil readily available to reverse the effects of midazolam, as it can cause prolonged sedation and hypoventilation.

    Buspirone Hydrochloride

    • Buspirone Hydrochloride is an antidepressant used for short-term treatment of anxiety.
    • It is available in oral form and has a dosage range of 5 mg to 30 mg daily, potentially reduced to 2.5 mg twice daily with concurrent use of potent CYP3A4 inhibitors.
    • Contraindications include epilepsy, angle-closure glaucoma, myasthenia gravis, and other conditions.
    • Side effects include abdominal pain, anger, chest pain, confusion, constipation, depression, diarrhea, dizziness, drowsiness, fatigue, headache, muscle spasms, nausea, skin reactions, sleep disorders, tachycardia, tremor, vomiting, and visual disturbances.
    • Exercise caution in patients with liver impairment and renal impairment.
    • Avoid buspirone use during pregnancy and lactation as it can potentially harm the fetus and pass through breast milk.
    • Closely monitor patients for signs of respiratory depression, especially at the initiation of treatment and when there are changes in prescribing, including dose adjustments or new interactions.
    • Inform patients about the signs and symptoms of respiratory depression, and urge them to seek urgent medical attention if they experience these issues.

    Palliative Care

    • Benzodiazepines can be administered by subcutaneous injection in palliative care.
    • The dosage varies based on the individual's needs.
    • Monitor patients receiving intensive care for response and adjust the dose accordingly, keeping the maximum daily dose within a range of 20-40 mg.
    • Continuous subcutaneous injection is recommended for patients under 3 months.
    • Unlicensed oromucosal formulations are available.
    • It is crucial to employ appropriate caution and dose adjustments, especially in patients with severe renal impairment, as the medication can accumulate in the body and lead to adverse effects.

    Benzodiazepines

    • High doses of benzodiazepines administered during late pregnancy or labor can cause neonatal hypothermia, hypotonia, and respiratory depression.
    • Patients with hepatic impairment should exercise caution with benzodiazepines.
      • Mild to moderate impairment: Caution advised.
      • Severe impairment: Avoidance recommended.
      • Manufacturers advise dose reduction for mild to moderate impairment and dose adjustments according to response.
    • Renal impairment is advised due to the increased risk of cerebral sensitivity to benzodiazepines.
    • Patients and caregivers should be advised to avoid driving and skilled tasks due to potential drowsiness, impaired judgment, and increased reaction time.
      • The hangover effects of a night dose may impair performance the following day.
    • Contra-indications for benzodiazepines:
      • Respiratory depression
      • Muscle weakness
      • Organic brain changes
    • Side effects of benzodiazepines:
      • Common or very common: Movement disorders
      • Rare or very rare:
        • Abdominal distress
        • Agranulocytosis
        • Bone marrow disorders
        • Erectile dysfunction
        • Leucopenia
        • Menstrual disorder
        • Skin eruption
        • Thrombocytopenia
        • Urinary incontinence
        • Vertigo
      • Frequency not known:
        • Specific side effects: Skin reactions, psychiatric disorder, psychosis, oral use, rectal use, chest pain

    Diazepam

    • Diazepam is a medication used to treat various conditions, including anxiety, depression, and muscle spasm.
    • It is administered orally or intramuscularly, with the preferred formulation being an emulsion formulation.
    • For intravenous use in children, the dosage is diluted to a maximum of 400 micrograms/mL with glucose 5% or 10%, with a maximum duration of 6 hours between addition and completion of infusion.
    • Intramuscular or intravenous use for adults:
      • The solution for injection should not be diluted, except for intravenous infusion.
      • The intramuscular route should only be used when oral and intravenous routes are not possible.
    • Contra-indications for Diazepam:
      • Chronic psychosis
      • Respiratory depression
      • Muscle weakness
      • Organic brain changes
    • Side effects of Diazepam:
      • Paradoxical effects may include increased hostility and aggression, talkativeness and excitement, aggressive and antisocial acts, and sometimes attenuated impulses.

    Attention Deficit Hyperactivity Disorder (ADHD)

    • ADHD is a behavioral disorder characterized by hyperactivity, impulsivity, and inattention.
    • Symptoms typically appear in children aged 3-7 years, but may not be recognized until after 7 years of age.
    • ADHD is more commonly diagnosed in males than in females.
    • ADHD is usually a persisting disorder, with some children continuing to have symptoms throughout adolescence and into adulthood.
    • ADHD is associated with an increased risk of disorders such as oppositional defiant disorder (ODD), conduct disorder, and possibly mood disorders such as depression, mania, anxiety, and substance misuse.

    Treatment of ADHD

    • The aims of treatment are to reduce functional impairment, severity of symptoms, and improve quality of life.
    • Non-drug treatment includes:
      • A balanced diet, good nutrition, and regular exercise.
      • Environmental modifications, such as seating arrangements, lighting, noise, reducing distractions, optimizing work or education, and reinforcing verbal requests with written instructions.
    • ADHD-focused psychological interventions, such as cognitive behavioral therapy (CBT), may be effective in patients who have refused drug treatment, have difficulty with adherence, are intolerant of, or unresponsive to drug treatment.
    • In patients who have benefited from drug treatment but whose symptoms are still causing significant impairment in at least one area of function, a combination of non-drug treatment with drug treatment should be considered.

    Atomoxetine for ADHD

    • Drug treatment should be initiated by a specialist trained in the diagnosis and management of ADHD.
    • Following dose stabilization, continuation, and monitoring of drug treatment can be undertaken by the patient's general practitioner under a shared care arrangement.
    • Treatment should be started in patients with ADHD whose symptoms are still causing significant impairment in at least one area of function, despite environmental modifications.
    • Atomoxetine (an unlicensed medication) is available in oral solution, oral suspension, and capsules.
    • The dosage of atomoxetine may differ from those in product literature.
    • Contraindications for Atomoxetine:
      • Phaeochromocytoma
      • Severe cardiovascular disease
      • Severe cerebrovascular disease
    • Atomoxetine has been shown to cause common or very common side effects such as:
      • Anxiety
      • Appetite decreased
      • Arrhythmias
      • Asthenia
      • Chills
      • Constipation
      • Depression
      • Dizziness
      • Drowsiness
      • Dry mouth
      • Feeling jittery
      • Flatulence
      • Gastrointestinal discomfort
      • Genital pain
      • Headaches
      • Hyperhidrosis
      • Menstrual cycle irregularities
      • Mood altered
      • Mydriasis
      • Nausea
      • Palpitations
      • Prostatitis
      • Sensation abnormal
      • Sexual dysfunction
      • Skin reactions
      • Sleep disorders
      • Taste altered
      • Thirst
      • Tremor
      • Urinary disorders
      • Vasodilation
      • Vomiting
      • Weight decreased
      • Unusual behavior abnormal
    • Monitoring requirements for Atomoxetine for ADHD include:
      • Monitoring for anxiety, depression, and tics.
      • Recording pulse, blood pressure, psychiatric symptoms, appetite, weight, and height at the initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.
    • Patients and their carers should be informed about the risk of suicidal ideation and hepatic impairment, and advised to report clinical worsening, suicidal thoughts or behavior, irritability, agitation, or depression.

    Methylphenidate Hydrochloride for ADHD

    • Methylphenidate hydrochloride is available in immediate-release and long-acting preparations.
    • Long-acting preparations include Concerta® XL, Delmosart® PROLONGED-RELEASE TABLET, EQUASYM® XL, MEDIKINET® XL, and XAGGITIN® XL.
    • These medications are taken by mouth and gradually increased at weekly intervals according to the patient's response.
    • The licensed maximum dose is 60 mg daily in 2–3 divided doses, with a maximum of 90 mg daily under the direction of a specialist.
    • If no response occurs after one month, a higher dose may be prescribed under the specialist's direction (unlicensed use).
    • Contraindications for methylphenidate include:
      • Anorexia nervosa
      • Arrhythmias
      • Cardiomyopathy
      • Cardiovascular disease
      • Cerebrovascular disorders
      • Heart failure
      • Hyperthyroidism
      • Mania
      • Phaeochromocytoma
      • Psychosis
      • Severe depression
      • Severe hypertension
      • Structural cardiac abnormalities
      • Suicidal tendencies
      • Uncontrolled bipolar disorder
      • Vasculitis
    • Cautions for methylphenidate include:
      • Agitation
      • Alcohol dependence
      • Anxiety
      • Drug dependence
      • Epilepsy
      • Family history of Tourette syndrome
      • Susceptibility to angle-closure glaucoma
      • Tics
    • Side effects of methylphenidate include:
      • Common or very common: Aggression, alopecia, anxiety, appetite decreased, arrhythmias, arthralgia, behavior abnormal, cough, depression, diarrhea, dizziness, drowsiness, dry mouth, fever, gastrointestinal discomfort, growth retardation (in children), headaches, hypertension, laryngeal pain, mood altered, movement disorders, nasopharyngitis, nausea, palpitations, sleep disorders, vomiting, weight decreased, mental health disorders
      • Rare or very rare: Anemia, angina pectoris, cardiac arrest, cerebrovascular insufficiency, confusion, gynaecomastia, hepatic coma, hyperfocus, hyperhidrosis, leucopenia, mydriasis, myocardial infarction, neuroleptic malignant syndrome, peripheral coldness, Raynaud’s phenomenon, seizures, sexual dysfunction, skin reactions, sudden cardiac death, thinking abnormal, thrombocytopenia.
      • Frequency not known: Delusions, drug dependence, hyperpyrexia, intracranial haemorrhage, logorrhea, pantopenia, vasculitis.

    Methylphenidate Hydrochloride

    • Different versions of modified-release preparations of methylphenidate may not have the same clinical effect.
    • Prescribers should specify the brand or manufacturer name when prescribing generic versions to avoid confusion between different formulations.
    • Methylphenidate is used to treat narcolepsy, refractory attention deficit hyperactivity disorder, and psychiatric disorders.
    • For narcolepsy in adults, methylphenidate is prescribed in divided doses with a maximum dosage of 60 mg per day.
    • For elderly individuals, the initial dose is 5 mg daily in divided doses, with a maximum dosage of 60 mg per day.
    • For refractory attention deficit hyperactivity disorder, treatment is initiated under specialist supervision for children aged 6-17 years.
    • Psychiatric disorders treated with methylphenidate include severe depression, schizophrenia, borderline personality disorder, and uncontrolled bipolar disorder.
    • Co-morbidity with psychiatric disorders is common in attention deficit hyperactivity disorder.
    • The manufacturer advises continuing use of methylphenidate only if the benefits outweigh the risks if new psychiatric symptoms develop or exacerbation occurs.
    • Cautions for methylphenidate use include a history of epilepsy, mild hypertension, susceptibility to angle-closure glaucoma, tics, and Tourette syndrome.
    • Discontinue methylphenidate use if seizures occur.
    • Monitor height and weight as growth restriction may occur during prolonged therapy.
    • Potential interactions with other medications include benzodiazepines.
    • Side effects of methylphenidate can include increased heart rate, increased blood pressure, and increased blood pressure.

    Amfetamines

    • Amfetamines can cause various side effects such as abdominal pain, anxiety, decreased appetite, arrhythmias, arthralgia, behavior abnormality, depression, dry mouth, headache, mood altered, movement disorders, muscle cramps, nausea, palpitations, poor weight gain, sleep disorders, vertigo, and vomiting.
    • Rare or very rare side effects include anemia, angina pectoris, cardiac arrest, central nervous system vasculitis, cerebrovascular insufficiency, fatigue, growth retardation, hallucination, hepatic coma, hepatic function abnormal, intracranial haemorrhage, leucopenia, mydriasis, psychosis, seizure, skin reactions, suicidal behaviors, thrombocytopenia, tic (in those at risk), vision disorders, acidosis, alopecia, cardiomyopathy, chest pain, circulatory collapse, colitis ischaemic, concentration impaired, confusion, diarrhoea, dizziness, drug dependence, hyperhidrosis, hypermetabolism, hyperpyrexia, kidney injury, myocardial infarction, neuroleptic malignant syndrome, obsessive-compulsive disorder, reflexes increased, rhabdomyolysis, sexual dysfunction, sudden death, taste altered, tremor, and overdose.
    • Overdose of amfetamines can cause wakefulness, excessive activity, paranoia, hallucinations, and hypertension, followed by exhaustion, convulsions, hyperthermia, and coma.
    • Pregnancy should be avoided due to retrospective evidence of uncertain significance suggesting possible embryotoxicity.
    • Breast feeding should be avoided due to the significant amount of amfetamines in milk.
    • Renal impairment should be used with caution.
    • Monitoring requirements include monitoring growth in children, monitoring for aggressive behavior or hostility during initial treatment, recording pulse, blood pressure, psychiatric symptoms, appetite, weight, and height at initiation of therapy, following each dose adjustment, and at least every six months thereafter.
    • Treatment cessation should avoid abrupt withdrawal.
    • Commonly available medicinal forms from special-order manufacturers include modified-release capsules, oral suspension, oral solution, tablets, and Lisdexamfetamine mesilate.
    • Lisdexamfetamine is a prodrug of dexamfetamine and has indications and doses for attention deficit hyperactivity disorder (ADHD) in children 6-17 years and adults 30 mg once daily, increasing in steps of 10-20 mg every week if required.

    Lisdexamfetamine

    • Lisdexamfetamine is a prodrug of dexamfetamine, used to treat attention deficit hyperactivity disorder (ADHD) and other conditions.
    • It is recommended for children aged 6-17 years and adults aged 30-60 years.
    • Overdose can lead to wakefulness, excessive activity, paranoia, hallucinations, and hypertension, followed by exhaustion, convulsions, hyperthermia, and coma.
    • The manufacturer recommends monitoring for aggressive behavior or hostility during initial treatment, pulse, blood pressure, and psychiatric symptoms before treatment initiation, following each dose adjustment, and at least every 6 months thereafter.
    • In adults, monitor weight before treatment initiation and during treatment.
    • In children, height and weight should be recorded before treatment initiation, and height, weight, and appetite monitored at least every 6 months during treatment.

    Guanfacine

    • Guanfacine is a medication used to treat attention deficit hyperactivity disorder (ADHD) in children for whom stimulants are not suitable, not tolerated, or ineffective.
    • It is indicated for children aged 6-12 years, 13-17 years, 49.5-58.4 kg, and 58.5 kg and above.
    • The manufacturer advises reducing the dose of guanfacine by half with concurrent use of moderate and potent inhibitors of CYP3A4.
    • The manufacturer also advises increasing the dose up to a maximum of 7 mg daily with concurrent use of potent inducers of CYP3A4.
    • Cautions for guanfacine use include Bradycardia, heart block, history of cardiovascular disease, history of QT-interval prolongation, and hypokalemia.
    • Elderly individuals may find the prescription potentially inappropriate for centrally-acting antihypertensives unless clear intolerance or lack of efficacy with other classes of antihypertensives is present.
    • Side effects of guanfacine include anxiety, appetite decreased, arrhythmias, asthenia, constipation, depression, diarrhea, dizziness, drowsiness, dry mouth, gastrointestinal discomfort, headache, hypotension, mood altered, nausea, skin reactions, sleep disorders, urinary disorders, vomiting, weight increased, uncommon asthma, atrioventricular block, chest pain, hallucination, loss of consciousness, pallor, seizure, syncope, hypertension, hypertensive encephalopathy, malaise, frequency not known, and erectile dysfunction.
    • Sumnolence and sedation may occur during the first 2-3 weeks of treatment and with dose increases; the manufacturer advises considering dose reduction or discontinuation of treatment if symptoms are clinically significant or persistent.
    • Overdose features may include hypotension, initial hypertension, bradycardia, lethargy, and respiratory depression.
    • Patients who develop lethargy should be observed for development of more serious toxicity for up to 24 hours.
    • The manufacturer recommends effective contraception in females of childbearing potential, avoid pregnancy, breast feeding, hepatic impairment, and renal impairment.
    • Dose adjustments may be required in severe impairment and end-stage renal disease.
    • Monitoring requirements include conducting a baseline evaluation to identify patients at risk of somnolence, sedation, hypotension, bradycardia, QT-prolongation, and arrhythmia, and monitoring blood pressure and pulse during dose downward titration and following discontinuation of treatment.
    • Treatment cessation is advised to avoid abrupt withdrawal and consider dose tapering to minimize potential withdrawal effects.

    Bipolar Disorder and Mania

    • Bipolar disorder is a condition characterized by acute episodes of mania or hypomania.
    • Patients with suspected bipolar disorder should be referred to a specialist mental health service for treatment, which should be initiated on specialist advice.
    • Antimanic drugs are used to manage and prevent episodes of mania.
    • Antidepressant drugs may also be required for the treatment of co-existing bipolar depression, but should be avoided in patients with rapid-cycling bipolar disorder, a recent history of mania or hypomania, or with rapid mood fluctuations.

    Antipsychotic Drugs for Bipolar Disorder

    • Antipsychotic drugs such as haloperidol, olanzapine, quetiapine, and risperidone are used to treat acute manic or hypomanic episodes.
    • Lithium or valproate can be added if the response to antipsychotics is inadequate.
    • In patients already taking lithium or valproate for prophylaxis, an antipsychotic drug can be used concurrently during acute episodes of mania.
    • Asenapine, a second-generation antipsychotic, is licensed for moderate to severe manic episodes associated with bipolar disorder.
    • Olanzapine is licensed for long-term management and preventing recurrence in patients whose manic episode responded to olanzapine treatment.
    • When discontinuing antipsychotics, reduce dosage gradually over at least 4 weeks to minimize recurrence risk.
    • Benzodiazepines, such as lorazepam, can be helpful for initial behavioral disturbance or agitation but should not be used long-term due to dependence risk.

    Lithium for Bipolar Disorder

    • Lithium salts (lithium carbonate and lithium citrate) treat acute episodes of mania or hypomania and are used long-term to prevent recurrence.
    • Lithium is a medication used to treat bipolar disorder, mania, and aggressive or self-harming behavior.
    • Lithium is contraindicated in patients with heart disease, cardiac disease, concurrent ECT, diuretic treatment, epilepsy, myasthenia gravis, psoriasis, and QT interval prolongation.
    • The therapeutic/toxic ratio of lithium salts is narrow, requiring facilities for monitoring serum-lithium concentrations.
    • Samples should be taken 12 hours after the dose to target a serum-lithium concentration of 0.4-1 mmol/litre for maintenance therapy and elderly patients.
    • In acute manic episodes, a target serum-lithium concentration of 0.8-1 mmol/litre is recommended.
    • Regular serum-lithium monitoring should be performed weekly after initiation.
    • Patients over 65 years old, using drugs that interact with lithium, or at risk for impaired renal or thyroid function require more frequent monitoring.
    • Assess renal, cardiac, and thyroid function before treatment initiation.
    • Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months.
    • Patients and their carers should be warned of the risk of relapse if lithium is discontinued abruptly.
    • If lithium is stopped or is to be discontinued abruptly, consider changing therapy to an atypical antipsychotic or valproate.
    • Patients should be advised to report signs and symptoms of lithium toxicity, hypothyroidism, renal dysfunction, and benign intracranial hypertension.
    • Maintain adequate fluid intake and avoid dietary changes that reduce or increase sodium intake.
    • Driving and skilled tasks may be impaired by lithium carbonate treatment.
    • Dosage and dose of lithium are based on serum-lithium concentration and should be adjusted according to the patient's age and body weight.
    • The CAMCOLIT ® IMMEDIATE-RELEASE TABLET is recommended for adults, with doses initially divided throughout the day.
    • The CAMCOLIT ® MODIFIED-RELEASE TABLET is recommended for adults, with doses initially divided throughout the day, but once daily administration is preferred when serum-lithium concentration stabilizes.
    • The LISKONUM ® treatment for mania, recurrent depression, and aggressive or self-harming behavior is recommended for adults, with doses initially divided throughout the day, but once daily administration is preferred when serum-lithium concentration stabilizes.

    Valproate for Bipolar Disorder

    • Carbamazepine is licensed for long-term management to prevent recurrence in patients unresponsive to lithium therapy.
    • Semisodium valproate is highly teratogenic and linked to neurodevelopmental disorders and congenital malformations.
    • Valproate must not be used in women and girls of childbearing potential unless specific conditions are met, and only if other treatments are ineffective or not tolerated, as judged by an experienced specialist.
    • Valproate is contra-indicated for migraine prophylaxis and bipolar disorder, and it must only be considered for epilepsy if there is no suitable alternative treatment.
    • Women and girls (and their carers) must be fully informed of valproate risks in pregnancy.
    • Supporting materials have been provided for the Pregnancy Prevention Programme.
    • GPs must recall all women of childbearing potential, provide the Patient Guide, check they have been reviewed by a specialist, and are on highly effective contraception.
    • Specialists must book in-review appointments annually with women under the Programme, re-evaluate treatment, explain conditions outlined in supporting materials, and complete the Risk Acknowledgement Form.
    • Pharmacists must ensure valproate medicines are dispensed in whole packs and discuss pregnancy risks with female patients each time valproate medicines are dispensed.
    • The MHRA advises that all healthcare professionals must identify and review all female patients on valproate, including off-label use, and provide patient information materials at every appointment.
    • Guidance for psychiatrists on withdrawal of, and alternatives to, valproate in women of childbearing potential who have a psychiatric illness is available from the Royal College of Psychiatrists.
    • The Annual Risk Acknowledgement Form was updated in April 2019, and should be used for all future reviews.
    • Specialists should comply with guidance on the form if they consider the patient is not at risk of pregnancy.
    • The MHRA has issued guidance to support healthcare professionals with the use of valproate during the COVID-19 pandemic.
    • The Guide for Healthcare Professionals has been updated and should be used for all future reviews of female patients on valproate medicines.
    • The MHRA has issued temporary guidance for female patients on valproate during the COVID-19 pandemic to support adherence to the Pregnancy Mental Health disorders (MHS) Prevention Programme.
    • The guide also advises considering vitamin D supplementation in patients who are immobile for long periods or have inadequate sun exposure or dietary intake of calcium.
    • Contra-indications for valproate include acute porphyrias, known or suspected mitochondrial disorders, personal or family history of severe hepatic dysfunction, urea cycle disorders, and systemic lupus erythematosus.
    • Liver toxicity has occurred in association with valproate, especially in children under 3 years.
    • Raised liver enzymes during valproate treatment are usually transient but patients should be reassessed clinically and liver function monitored until return to normal.
    • The MHRA advises that all women and girls of childbearing potential being treated with valproate medicines must be supported on a Pregnancy Prevention Programme.
    • If valproate is to be used during pregnancy, the lowest effective dose should be prescribed in divided doses to avoid peaks in plasma-valproate concentrations.
    • Neonatal bleeding and hepatotoxicity have also been reported.
    • Senior prenatal monitoring should be initiated when valproate has been taken in pregnancy.
    • Breast feeding present in milk raises the risk of haematological disorders in breast-fed newborns and infants.
    • Valproate is a medication used to treat bipolar disorder, a mood disorder associated with mood swings.
    • Patients or their carers should be taught how to recognize signs and symptoms of blood or liver disorders and advised to seek immediate medical attention if symptoms develop.
    • Patients or their carers should also be told to recognize signs and symptoms of pancreatitis and advised to seek immediate medical attention if symptoms such as abdominal pain, nausea, or vomiting develop.
    • There can be variation in the licensing of different medicines containing the same drug.
    • Forms available from special-order manufacturers include oral suspension, oral solution, and gastro-resistant capsules.

    Asenapine for Bipolar Disorder

    • Asenapine is another medication used for treating bipolar disorder.
    • It is recommended to use it only if potential benefit outweighs risk, as toxicity in animal studies has been observed.
    • Breast feeding is advised to discontinue, as it is present in milk in animal studies.
    • Hydroxycin is advised in moderate impairment, and renal impairment is used with caution if creatinine clearance is less than 15 mL/minute.
    • Sublingual tablets are used for asenapine administration, and patients should not consume food or drink for at least 10 minutes after administration.
    • When used as combination therapy, asenapine sublingual tablets should be administered last.
    • Patients or carers should be given advice on how to administer asenapine sublingual tablets.

    Depression

    • Depression is a common condition characterized by low mood, loss of interest or pleasure in activities, and emotional, cognitive, physical, and behavioral symptoms.
    • It is one of the leading causes of disability and can have a significant detrimental effect on an individual's life.
    • Risk factors for depression include personal or family history of depressive illness, history of other mental health conditions, chronic comorbidities, female sex, recent childbirth, older age, and psychosocial issues.
    • Depression severity depends on the intensity, frequency, and duration of symptoms, and their impact on daily functioning.
    • Treatment aims to improve mood, quality of life, and reduce relapse or recurrence risk.
    • Patients with depression should be assessed for the risk of suicide, comorbid conditions, and other risk factors.
    • Lifestyle changes such as regular physical activity, eating a healthy diet, not over-using alcohol, and getting enough sleep should be encouraged.
    • The choice of treatment for depression should be based on the patient's clinical needs, preference, and response to any previous treatment.
    • Treatment options may include antidepressants and/or psychological and psychosocial treatment (guided self-help, cognitive behavioural therapy, behavioural activation, group physical activity, group mindfulness, interpersonal psychotherapy, counseling, or short-term psychodynamic psychotherapy).
    • Patients receiving treatment should be monitored for suicidal ideation and treatment concordance.
    • Patients and their families/carers should be advised to be vigilant for worsening behavioral symptoms, especially during high-risk periods, and to seek help from a healthcare professional if concerned.
    • Response to treatment should be reviewed 2 to 4 weeks after initiation, with patients on antidepressants usually reviewed within 2 weeks of initiation.
    • Discontinuation of an antidepressant usually involves a step-wise dose reduction.
    • Successful withdrawal of an antidepressant drug may take weeks or months to complete.
    • Management of depression during pregnancy and the postnatal period should consider potential risks and benefits of treatments, patient preference, and risks from untreated depression.
    • Before starting any treatment, discuss the higher threshold for intervention with drug treatment due to the changing risk-benefit ratio and the likely benefits of psychological treatment.
    • Specialist advice, preferably from a specialist in perinatal mental health, should be sought if there is uncertainty about the risks associated with specific drug treatments.
    • For patients with subthreshold or mild depression, psychological and psychosocial therapy should be considered as first-line treatment options.
    • Antidepressants should not be offered routinely unless it is the patient's preference.
    • If antidepressants are preferred, an SSRI (Serotonin Reuptake Inhibitor) such as citalopram, escitalopram, sertraline, fluoxetine, fluvoxamine maleate, or paroxetine should be offered.
    • For patients who decide against treatment, offer active monitoring with the option to reconsider treatment at any time.
    • For patients with moderate or severe depression, combination therapy with an antidepressant and individual CBT should ideally be offered.
    • SSRIs should be considered as the first choice of antidepressant treatment due to their well-tolerated and good safety profile.
    • Other antidepressant options include serotonin and noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressant (TCA), and electroconvulsive therapy (ECT) for severe depression.
    • If antidepressant treatment is not working after 4 weeks, assess for treatment adherence and consider other factors or health conditions that may be contributing.
    • For patients with limited or no response to psychological monotherapy, consider switching to an alternative psychological treatment, adding in an SSRI, or switching to an SSRI alone.

    Antidepressant Treatment Options

    • Consider adding group exercise intervention, switching to psychological therapy, increasing antidepressant dose, switching to a different antidepressant in the same class or different class, or combining psychological therapy and an antidepressant, if there is limited or no response to antidepressant monotherapy.
    • If switching to an antidepressant from a different class, adding in an additional antidepressant from a different class, combining antidepressants with ECT, transcranial magnetic stimulation, and implanted vagus nerve stimulation, seek specialist advice.
    • Relapse prevention is crucial in managing depression.
    • Patients in remission following psychological treatment alone but at higher risk of relapse should consider continuing psychological therapy.
    • Patients on antidepressant monotherapy who are in remission but at higher risk of relapse should consider continuing the antidepressant, combining the antidepressant with a course of psychological therapy (such as group CBT or MBCT), or switching to a course of psychological therapy alone.
    • Patients in remission following combination treatment with an antidepressant and psychological therapy who are at higher risk of relapse should consider continuing one or both treatments.
    • For chronic depressive symptoms, treatment options include monotherapy with either CBT or drug treatment with an SSRI, SNRI, or a TCA; or combination therapy with CBT and either an SSRI or a TCA.
    • Consider alternative drug treatments in specialist settings or on specialist advice, for patients who do not respond to SSRIs or SNRIs.
    • The major classes of antidepressant drugs include tricyclic and related antidepressants, selective serotonin re-uptake inhibitors (SSRIs), and the monoamine oxidase inhibitors (MAOIs).

    Managing Depression

    • Review patients every 1–2 weeks at the start of antidepressant treatment.
    • Continue treatment with the same dose for at least 6 months after remission.
    • Monitor patients with suicidal thoughts and behavior, particularly children, young adults, and those with a history of suicidal behavior for suicidal behavior, self-harm, or hostility.

    Serotonin Syndrome

    • Serotonin syndrome is an adverse drug reaction caused by excessive central and peripheral serotonergic activity.
    • Symptoms can range from mild to life-threatening and can occur within hours or days following the initiation, dose escalation, or overdose of a serotonergic drug, the addition of a new serotonergic drug, or the replacement of one serotonergic drug by another without allowing a long washout period in-between.
    • Treatment consists of withdrawal of serotonergic medication and supportive care; specialist advice should be sought.
    • Severe toxicity, which is a medical emergency, usually occurs with a combination of serotonergic drugs, one of which is generally an MAOI.

    Managing Anxiety

    • Management of acute anxiety generally involves the use of a benzodiazepine or buspirone hydrochloride.
    • For chronic anxiety (lasting longer than 4 weeks), it may be appropriate to use an antidepressant.
    • Combined therapy with a benzodiazepine may be required until the antidepressant takes effect.
    • Patients with generalized anxiety disorder should be offered psychological treatment before initiating an antidepressant.
    • Serotonin reuptake inhibitors (SSRIs) such as escitalopram, paroxetine, or sertraline can be used for the treatment of generalised anxiety disorder.
    • Clomipramine hydrochloride or imipramine hydrochloride can be used second-line for panic disorder.
    • Obsessive-compulsive disorder, post-traumatic stress disorder, and phobic states such as social anxiety disorder are treated with SSRIs.
    • Tricyclic and related antidepressants block the re-uptake of both serotonin and noradrenaline.
    • They can be roughly divided into those with additional sedative properties and those that are less sedating.
    • Agitated and anxious patients tend to respond best to the sedative compounds, while withdrawn and apathetic patients will often obtain most benefit from the less sedating ones.
    • Tricyclic and related antidepressants also have varying degrees of antimuscarinic side-effects and cardiotoxicity in overdosage.
    • About 10 to 20% of patients fail to respond to tricyclic and related antidepressant drugs.
    • Low doses should be used for initial treatment in the elderly, and modified release preparations should be avoided.
    • Some tricyclic antidepressants are used in the management of panic and other anxiety disorders.
    • Some tricyclic antidepressants may also have a role in some forms of neuralgia and nocturnal enuresis in children.

    Monoamine-oxidase Inhibitors (MAOIs)

    • MAOIs are less frequently used than tricyclic and related antidepressants or SSRIs and related antidepressants due to the dangers of dietary and drug interactions.
    • Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid and is more likely to cause a hypertensive crisis.
    • Isocarboxazid and phenelzine are more likely to cause hepatotoxicity than tranylcypromine.
    • Moclobemide should be reserved as a second line treatment.
    • Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features are said to respond best to MAOIs.
    • MAOIs should be tried in any patients who are refractory to treatment with other antidepressants.
    • Response to treatment may be delayed for 3 weeks or more.

    MAOI Interactions with Other Medications

    • Interactions with other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped.
    • An MAOI should not be started until at least 2 weeks after a previous MAOI has been stopped, at least 7-14 days after a tricyclic or related antidepressant has been stopped, or at least a week after an SSRI or related antidepressant has been stopped.

    Agomelatine

    • Agomelatine is a melatonin receptor agonist and selective serotonin-receptor antagonist.
    • Side effects include abdominal pain, anxiety, back pain, constipation, diarrhea, dizziness, drowsiness, fatigue, headaches, nausea, sleep disorders, vomiting, weight changes, aggression, confusion, hyperhidrosis, mood altered, movement disorders, paraesthesia, skin reactions, suicidal behaviors, tinnitus, vision blurred, angioedema, face oedema, hallucination, hepatic disorders, and urinary retention.

    General Antidepressant Medication Considerations

    • The use of antidepressants has been linked with suicidal thoughts and behavior, particularly in children, young adults, and patients with a history of suicidal behavior.
    • Patients should be monitored for suicidal behavior, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed.

    Nardil

    • Nardil is used to treat various disorders, including depression, anxiety, and neuropathic malignant syndrome.
    • It is prescribed in doses of 10 mg twice daily, with the usual dosage being 150-600 mg daily.
    • Side effects include hepatocellular injury, chest pain, diarrhea, drug dependence, extrasystole, flushing, hypertension, hypomania, mydriasis, pain, pallor, photophobia, sleep disorder, and throbbing headache.

    Moclobemide

    • Moclobemide is an antidepressant that acts by reversible inhibition of monoamine oxidase type A (RIMA).
    • Side effects include anxiety, constipation, diarrhoea, dizziness, dry mouth, headache, hypotension, irritability, nausea, paraesthesia, skin reactions, sleep disorder, vomiting, asthma, confusion, flushing, oedema, suicidal behaviors, taste altered, visual impairment, and rare or very rare appetite decreased, delusions, hyponatraemia, and serotonin syndrome.

    Reboxetine

    • Reboxetine is used to treat major depression in adults aged 18-65 years.
    • Side effects include accommodation disorder, anxiety, appetite decreased, chills, constipation, dizziness, dry mouth, headache, hyperhidrosis, hypertension, hypotension, insomnia, nausea, palpitations, paraesthesia, sexual dysfunction, skin reactions, tachycardia, taste altered, urinary disorders, urinary tract infection, vasodilation, vomiting, uncommon mydriasis, vertigo, rare or very rare glaucoma, aggression, hallucination, hyponatraemia, irritability, peripheral coldness, potassium depletion (long term use), Raynaud's phenomenon, suicidal behaviors, and testicular pain.

    Edronax

    • Edronax is a selective serotonin re-uptake inhibitor that selectively inhibits the re-uptake of serotonin (5-hydroxytryptamine, 5-HT).
    • SSRIs are known to increase the risk of bleeding due to their effect on platelet function.
    • An EU review of observational data found a slightly increased risk of postpartum haemorrhage associated with the use of SSRIs during the month before delivery.
    • Side effects include anxiety, appetite abnormalities, arrhythmias, arthralgia, asthenia, concentration impaired, confusion, constipation, depersonalization, diarrhea, dizziness, drowsiness, fever, gastrointestinal discomfort, haemorrhage, headache, hyperhidrosis, malaise, memory loss, menstrual cycle irregularities, myalgia, mydriasis, nausea, palpitations, paraesthesia, QT interval prolongation, sexual dysfunction, skin reactions, sleep disorders, taste altered, tinnitus, tremor, urinary disorders, visual impairment, vomiting, weight changes, yawning, uncommon alopecia, angioedema, behavior abnormal, hallucination, mania, movement disorders, photosensitivity reaction, postural hypotension, seizure, suicidal behaviors, syncope, Galactorrhoea, hepatitis, hyperprolactinaemia, hyponatraemia, serotonin syndrome, severe cutaneous adverse reactions (SCARs), SIADH, thrombocytopenia, and withdrawal syndrome.

    Dronax

    • Dronax is a medication used to treat depression.
    • It is known to increase the risk of bleeding due to their effect on platelet function.
    • An EU review of observational data found a slightly increased risk of postpartum haemorrhage associated with the use of SSRIs during the month before delivery.
    • Side effects include anxiety, appetite abnormalities, arrhythmias, arthralgia, asthenia, confusion, constipation, depersonalization, diarrhea, dizziness, drowsiness, fever, gastrointestinal discomfort, haemorrhage, headache, hyperhidrosis, malaise, memory loss, menstrual cycle irregularities, myalgia, mydriasis, nausea, palpitations, paraesthesia, QT interval prolongation, sexual dysfunction, skin reactions, sleep disorders, taste altered, tinnitus, tremor, urinary disorders, visual impairment, vomiting, weight changes, yawning, uncommon alopecia, angioedema, behavior abnormal, hallucination, mania, movement disorders, photosensitivity reaction, postural hypotension, seizure, suicidal behaviors, syncope, rare or very rare galactosis, hepatitis, hyperprolactinaemia, hyponatraemia, serotonin syndrome, severe cutaneous adverse reactions (SCARs), SIADH, thrombocytopenia, and withdrawal syndrome.

    Cipramil®

    • Cipramil® is used to treat depression, anxiety, and pain.
    • The drug’s side effects include sexual dysfunction, overdose, and severe poisoning.
    • Symptoms of poisoning include nausea, vomiting, agitation, tremor, nystagmus, drowsiness, sinus tachycardia, convulsions, and rare serotonin syndrome.
    • Pregnancy is advised to avoid SSRIs unless the potential benefit outweighs the risk.
    • Treatment can result in gastrointestinal disturbances, headaches, anxiety, dizziness, paraesthesia, electric shock sensation, tinnitus, sleep disturbances, fatigue, influenza-like symptoms, and sweating.
    • Withdrawal effects may occur within 5 days of stopping treatment with antidepressant drugs, usually mild and self-limiting, but in some cases may be severe.

    Escitalopram

    • Escitalopram is an active enantiomer of citalopram, used for treating depression, generalized anxiety disorder, obsessive-compulsive disorder, and pain disorders.
    • It is recommended for adults to take 10 mg once daily, increased if necessary, and at appropriate intervals.

    Escitalopram

    • Dosage:
      • Elderly Individuals: Start with 5 mg daily, increase to 10 mg daily
      • Social Anxiety Disorder: 10 mg once daily for 2-4 weeks, usual dose is 5-20 mg daily
      • Hepatic Impairment: Mild to Moderate: 5 mg once daily for 2 weeks, then increase to 10 mg once daily
    • Treatment Duration:
      • Adjust dosage after 2-4 weeks of treatment.
      • Gradually reduce treatment over 4 weeks (up to 6 months for long-term maintenance)
    • Administration:
      • Oral drops can be mixed with water, orange juice, or apple juice.
      • Patient and caregiver counseling needed for administering oral drops.
      • Patients should receive counseling about the effects on driving.
      • Fluoxetine is a different medication containing the same drug but with different indications and doses.

    Fluoxetine

    • Dosage:
      • Major Depression: 20 mg daily, increased after 3-4 weeks if necessary.
      • Maximum Dose: 60 mg per day
      • Elderly Individuals: Up to 40 mg daily, with a maximum of 60 mg daily.
      • Obsessive-Compulsive Disorder: Single or divided dose, with a maximum of 60 mg per day.
      • Menopausal Symptoms: 20 mg once daily (not licensed for this indication)
    • Side Effects:
      • Common: Chills, feeling abnormal, postmenopausal haemorrhage, vasodilation, blurred vision, cold sweats, dysphagia, dyspnoea, hypotension, mood changes, muscle twitching, self-injurious behavior, altered temperature sensation, abnormal thinking.
      • Rare: Buccoglossal syndrome, leucopenia, neutropenia, oesophageal pain, pharyngitis, respiratory disorders, serum sickness, speech disorder, vasculitis
      • Not Known Frequency: Bone fracture, breast feeding, breath feeding present in milk
    • Hepatic Impairment: Manufacturer advises dose reduction or increased dose interval.
    • Administration: Dispersible tablets can be dispersed in water for administration or swallowed whole.

    Paroxetine

    • Dosage:
      • Major Depression: Adults and Elderly: Up to 20 mg daily
      • Obsessive-Compulsive Disorder: Increased gradually to 40 mg daily
      • Menopausal Symptoms: 10 mg once daily (not licensed for this indication)
    • Side Effects:
      • Common: Blurred vision, impaired diabetic control
      • Rare: Acute glaucoma, hepatic disorders, peripheral oedema
    • Pregnancy: Increased risk of congenital malformations, especially in the first trimester.
    • Breastfeeding: Present in milk, but too small to be harmful.
    • Hepatic Impairment: Use dose at the lower end of the range.
    • Renal Impairment: Use with caution if creatinine clearance is less than 30 mL/minute.
    • Withdrawal Symptoms: Reduce dose gradually over 4 weeks or longer.
    • Administration: Available as oral suspension and oral solution.

    Sertraline

    • Dosage:
      • Depression, Obsessive-Compulsive Disorder, Pain Disorder, Post-traumatic Stress Disorder, and Social Anxiety Disorder:
        • Adults: Start at 50 mg daily.
        • Increase in steps of 50 mg at intervals of at least one week if needed.
        • Maximum: 200 mg per day
    • Side Effects:
      • Common: Chest pain, depression, gastrointestinal disorders, increased risk of infection, neuromuscular dysfunction, vasodilation, back pain, burping, chills, cold sweats, dysphagia, dyspnoea, ear pain, euphoric mood, hypertension, hypothyroidism, migraine, muscle complaints, muscle weakness, oedema, oral disorders, osteoarthritis, periorbital oedema, respiratory disorders, abnormal sensation, speech disorder, abnormal thinking, thirst.
      • Rare: Balanoposthitis, bone disorder, cardiac disorder, coma, conversion disorder, diabetes mellitus, drug dependence, dysphonia, eye disorders, abnormal gait, genital discharge, glaucoma, abnormal hair texture, hepatic disorders, hiccups, hypercholesterolaemia, hypoglycaemia, injury lymphadenopathy, myocardial infarction, neoplasms, oliguria, peripheral ischaemia, psychotic disorder, rhabdomyolysis, vasodilation procedure, vision disorders, vulvovaginal atrophy, cerebrovascular insufficiency, gynaecomastia, hyperglycaemia, leucopenia, neuroleptic malignant syndrome, pancreatitis.
    • Hepatic Impairment: Avoid in severe impairment. Adjust dose in mild to moderate impairment.
    • Withdrawal Symptoms: Reduce treatment gradually over 4 weeks or longer..
    • Administration: Available as tablets and oral suspensions.

    Duloxetine

    • Dosage:
      • Major Depressive Disorder, Generalized Anxiety Disorder, Diabetic Neuropathy, Moderate to Severe Stress Urinary Incontinence:
        • Adults: 60 mg once daily (initially 30 mg daily)
        • Maximum: 120 mg per day
    • Side Effects:
      • Common: Anxiety, constipation, diarrhea, dizziness, drowsiness, dry mouth, falls, fatigue, flushing, GI discomfort, headache, muscle complaints, nausea, pain, palpitations, paraesthesia, sexual dysfunction, skin reactions, sleep disorders, sweat changes, tinnitus, tremor, urinary disorders, vision disorders, vomiting, weight changes, yawning
      • Other: Anxiety, apathy, arrhythmias, abnormal behavior, burping, chills, impaired concentration, disorientation, dysphagia, ear pain, feeling abnormal, abnormal gait, hemorrhage, hepatic disorders, hyperglycemia, increased risk of infection, malaise, menstrual disorders, movement disorders, mydriasis, peripheral coldness, photosensitivity reaction, postural hypotension, suicidal behaviors, syncope, altered taste, altered temperature sensation, testicular pain, thirst, throat tightness, vertigo.
    • Interactions:
      • SNRIs: May interact with other medications.
    • Pregnancy: Avoid in patients with stress urinary incontinence. Use only if potential benefit outweighs risk.
    • Breastfeeding: Manufacturer advises against breastfeeding.
    • Hepatic and Renal Impairment: Manufacturer advises against use.
    • Withdrawal: Gradually reduce treatment dose. Abrupt withdrawal or marked reduction of dose is not recommended.

    Venlafaxine

    • Dosage:
      • Major Depression: 75 mg daily (up to 375 mg daily)
      • Generalized Anxiety Disorder: Up to 225 mg daily
      • Social Anxiety Disorder: Up to 225 mg daily
      • Menopausal Symptoms: 37.5 mg once daily for one week, then 75 mg once daily if needed.
    • Side Effects:
      • Common: Anxiety, decreased appetite, arrhythmias, asthenia, chills, confusion, constipation, depersonalization, diarrhea, dizziness, dry mouth, dyspnoea, headache, hot flush, hypertension, menstrual cycle irregularities, movement disorders, increased muscle tone, mydriasis, nausea, palpitations, paraesthesia, sedation, sexual dysfunction, skin reactions, sleep disorders, sweat changes, altered taste, tinnitus, tremor, urinary disorders, vision disorders, vomiting, weight changes, yawning
      • Rare: Agranulocytosis, angle closure glaucoma, bone marrow disorders, delirium, hepatitis, hyponatraemia, neuroleptic malignant syndrome, neutropenia, pancreatitis, QT interval prolongation, respiratory disorders, rhabdomyolysis, seizure, serotonin syndrome, severe cutaneous adverse reactions (SCARs), SIADH, thrombocytopenia
      • Not Known Frequency: Suicidal behaviors, vertigo, withdrawal syndrome
    • Pregnancy: Avoid unless potential benefit outweighs risk.
    • Breastfeeding: Avoid breastfeeding.
    • Hepatic and Renal Impairment: Manufacturer advises caution.
    • Withdrawal: Increased risk of withdrawal effects compared to other antidepressants.
    • Administration: Available as tablets, modified-release capsules, and oral solutions.

    Tricyclic Antidepressants

    • Dosage:
      • Adults: 150 mg daily in divided doses, or 150 mg once daily at bedtime.
      • Elderly: 100 mg daily, or 100 mg once daily at bedtime.
      • Maximum Dose: 600 mg daily (higher doses only for hospitalized patients).
    • Contraindications:
      • Manic phase of bipolar disorder
      • Immediate recovery period after myocardial infarction
    • Cautions:
      • Arrhythmias, cardiovascular disease, chronic constipation, epilepsy, history of bipolar disorder, history of psychosis, hyperthyroidism, increased intra-ocular pressure, patients with a significant risk of suicide, prostatic hypertrophy, susceptibility to angle-closure glaucoma, and urinary retention.
    • Side Effects:
      • Common:
        • Aggression, agranulocytosis, decreased alertness, anemia, anxiety, aphasia, abnormal appetite, arrhythmias, arthralgia, asthenia, blood disorder, chest pain, confusion, constipation, delirium, delusions, diarrhea, dizziness, drowsiness, dry mouth, dyspnea, eosinophilia, fever, gastroenteritis, GI discomfort, hallucination, headache, hepatic disorders, hyperhidrosis, hypersalivation, hypertension, hyponatraemia, influenza-like illness, jaundice, leucopenia, decreased libido, mania, memory loss, movement disorders, myalgia, nasal congestion, nausea, neuroleptic malignant syndrome, oedema, pain, palpitations, paraesthesia, paralytic ileus, postural hypotension, priapism, QT interval prolongation, seizure, serotonin syndrome, SIADH, skin reactions, sleep disorders, suicidal behaviors, syncope, altered taste, thrombocytopenia, tremor, urinary disorder, vertigo, blurred vision, vomiting, decreased weight, withdrawal syndrome
      • Overdose:
        • Lower risk of cardiotoxicity.
        • May cause dry mouth, coma, hypotension, hypothermia, hyperreflexia, extensor plantar responses, convulsions, respiratory failure, cardiac conduction defects, arrhythmias.
        • Dilated pupils and urinary retention can also occur.
    • Pregnancy: Avoid due to limited available information.
    • Breastfeeding: Monitor for signs of withdrawal.
    • Hepatic and Renal Impairment: Use with caution.
    • Withdrawal: May occur within 5 days of stopping treatment. Gradually reduce dosage over 4 weeks or longer.
    • Administration: Available as oral suspension, tablets, capsules, and tablets.
    • Indications: Depressive illness
    • Contraindications:
      • Acute porphyrias, heart block, history of bipolar disorder, psychosis, immediate recovery period after myocardial infarction, increased intra-ocular pressure, patients with a significant risk of suicide, phaeochromocytoma, prostatic hypertrophy, susceptibility to angle-closure glaucoma, and withdrawal syndrome.
    • Side Effects:
      • Common:
        • Granulocytosis, arthritis, bone marrow disorders, breast abnormalities, dizziness, granulocytopenia, gynaecomastia, hepatic disorders, hyperhidrosis, hyponatraemia, joint disorders, lactation, leucopenia, mood changes, neuromuscular irritability, oedema, paranoid delusions, postural hypotension, psychosis, rash, seizure, sexual dysfunction, suicidal behaviors, tremor, and withdrawal syndrome.
      • Overdose: Lower risk of cardiotoxicity.
    • Pregnancy: Avoid.
    • Breastfeeding: Amount secreted into breast milk is too small to be harmful.
    • Hepatic Impairment: Use with caution.
    • Renal Impairment: Use with caution.
    • Monitoring: Full blood count every 4 weeks during the first 3 months of treatment.
    • Withdrawal: May occur within 5 days of stopping treatment, usually mild and self-limiting, but can be severe in some cases.
    • Administration: Available as oral suspension, tablets, capsules, and tablets.

    Tricyclic Antidepressants

    • Tricyclic antidepressants are prescribed for depressive illness and can be taken in various forms, including oral suspension, tablets, capsules, and tablets.
    • Limited quantities should be prescribed due to their cardiovascular and epileptogenic effects.
    • Drowsiness and alcohol-enhanced effects are potential risks.
    • The dose should be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge.
    • Withdrawal effects may occur within 5 days of stopping treatment, usually mild and self-limiting, but in some cases may be severe.

    Mirtazapine

    • Mirtazapine is a presynaptic alpha2-adrenoreceptor antagonist that increases central noradrenergic and serotonergic neurotransmission.
    • It is prescribed for major depression in adults.
    • Dosages range from 15-30 mg daily for 2-4 weeks.
    • Potential side effects include anxiety, appetite increased, arthralgia, back pain, confusion, constipation, diarrhea, dizziness, drowsiness, dry mouth, fatigue, headache, myalgia, nausea, oedema, postural hypotension, sleep disorders, tremor, vomiting, weight increase, hallucination, mania, movement disorders, oral disorders, syncope, rare or very rare aggression, pancreatitis, granulocytosis, arrhythmias, bone marrow disorders, dysarthria, eosinophilia, granulocytopenia, hyponatraemia, jaundice, QT interval prolongation, rhabdomyolysis, seizure, serotonin syndrome, severe cutaneous adverse reactions (SCARs), SIADH, skin reactions, sudden death, suicidal behaviors, thrombocytopenia, urinary retention, and withdrawal syndrome.

    Amitriptyline Hydrochloride

    • Amitriptyline is a tricyclic antidepressant used to treat various mental health disorders, including major depressive disorder, neuropathy, migraines, chronic tension type headaches, and multiple sclerosis.
    • It is not licensed for use in abdominal pain or discomfort in patients who have not responded to other medications.
    • Contra-indications include arrhythmias during the manic phase of bipolar disorder, heart block, immediate recovery period after myocardial infarction, and cardiovascular disease.
    • The risks of side effects include cardiovascular disease, chronic constipation, diabetes, epilepsy, history of bipolar disorder, psychosis, hyperthyroidism, increased intra-ocular pressure, patients with a significant risk of suicide, phaeochromocytoma, prostatic hypertrophy, pyloric stenosis, susceptibility to angle-closure glaucoma, urinary retention, and more.
    • Elderly patients are particularly susceptible to many of the side-effects of tricyclic antidepressants, and low initial doses should be used, particularly for psychiatric and cardiac side-effects.

    Clomipramine Hydrochloride

    • Clomipramine hydrochloride is a non-proprietary medication that can be taken in various forms, including modified-release tablets, oral suspension, and oral solution.
    • Contra-indications include acute porphyrias, arrhythmias, heart block, and immediate recovery period after myocardial infarction.
    • Cautions include cardiovascular disease, chronic constipation, diabetes, epilepsy, history of bipolar disorder, psychosis, hyperthyroidism, increased intra-ocular pressure, patients with a significant risk of suicide, phaeochromocytoma, prostatic hypertrophy, susceptibility to angle-closure glaucoma, urinary retention, and mental health disorders.

    Dosulepin Hydrochloride

    • Dosulepin hydrochloride is less suitable for prescribing due to its potential risks, including arrhythmias, cardiovascular disease, chronic constipation, diabetes, epilepsy, heart block, history of bipolar disorder, psychosis, hyperthyroidism, immediate recovery period after myocardial infarction, increased intra-ocular pressure, patients with a significant risk of suicide, phaeochromocytoma, prostatic hypertrophy, susceptibility to angle-closure glaucoma, and urinary retention.

    Tricyclic Antidepressants

    • Lofepramine has the lowest risk of fatality in overdose compared to other tricyclic antidepressants.
    • Tricyclic antidepressants can cause various side effects like agranulocytosis, alopecia, anxiety, decreased appetite, arrhythmias, asthenia, atrioventricular block, and many more.
    • Tricyclic antidepressants are used to treat depression, especially in patients with mental health disorders and the nervous system.
    • Adults should take 50-75 mg daily in divided doses, or 150-300 mg daily if necessary.
    • Elderly patients should take 10-25 mg three times a day, with maintenance doses of 75-150 mg daily.
    • Contraindications include acute porphyrias, arrhythmias, heart block, and immediate recovery period after myocardial infarction.
    • Cautions include cardiovascular disease, chronic constipation, diabetes, epilepsy, history of bipolar disorder, psychosis, hyperthyroidism, increased intra-ocular pressure, patients with a significant risk of suicide, phaeochromocytoma, prostatic hypertrophy, susceptibility to angle-closure, glaucoma, urinary retention, and potential side effects.

    Tryptophan

    • Tryptophan is an essential dietary amino acid and precursor of serotonin, which reduces anxiety and depression by re-establishes the inhibitory action of serotonin on the amygdaloid nuclei.
    • Treatment-resistant depression can be treated with tryptophan, with adult dosages ranging from 1 g to 6 g per day.
    • There are contraindications for patients with eosinophilia myalgia syndrome (EMS), asthenia, dizziness, drowsiness, headache, myalgia, myopathy, nausea, oedema, and suicidal behaviors.
    • Pregnancy is advised with caution, and breastfeeding should be avoided.

    Vortioxetine

    • Vortioxetine inhibits the re-uptake of serotonin (5-HT) and is an antagonist at 5-HT3 and an agonist at 5-HT1A receptors.
    • Major depression dosages are given to adults and elderly patients, with dosages ranging from 5-20 mg once daily.
    • Cautions include bleeding disorders, liver cirrhosis, elderly patients, history of mania, seizures, susceptibility to angle-closure glaucoma, unstable epilepsy, seizures, and elderly patients with doses over 10mg daily.
    • Treatment discontinuation is advised in patients who develop seizures or if there is an increase in seizure frequency.
    • Pregnancy is advised to avoid unless potential benefit outweighs risk, as toxicity in animal studies has been reported.
    • Breast feeding should be avoided, and hepatic impairment should be used with caution.
    • Treatment can be stopped abruptly without need for gradual dose reduction.

    Benperidol

    • Benperidol is a first-generation antipsychotic medication used to control deviant antisocial sexual behavior.
    • Adults should take 0.25-1.5 mg daily in divided doses, adjusted according to response.
    • Elderly patients should use 0.125-0.75 mg daily.
    • Contraindications include CNS depression, comatose states, and phaeochromocytoma.
    • Risk factors for stroke include a decrease in appetite, blood disorders, cardiac arrest, depression, dyspepsia, headache, hepatic disorders, hyperhidrosis, hypersalivation, hypertension, nausea, oculogyric crisis, oedema, oligomenorrhoea, paradoxical drug reaction, pruritus, psychiatric disorder, temperature regulation disorders, and weight change.
    • Nephtheria has been reported with extrapyramidal effects and withdrawal syndrome in neonates when antipsychotic drugs are taken during the third trimester of pregnancy.
    • Neonatal symptoms include agitation, hyperterria, hypotonia, tremor, drowsiness, feeding problems, and respiratory distress.
    • Breast-feeding has limited information on the short- and long-term effects of antipsychotic drugs on the developing nervous system.

    Antipsychotic Drugs

    • Antipsychotic drugs, also known as neuroleptics, are used for various mental health disorders, including schizophrenia and bipolar disorder.
    • Schizophrenia is the most common psychotic disorder, with symptoms divided into positive symptoms like hallucinations and delusions, and negative symptoms like emotional apathy and social withdrawal.
    • The initial aim of treatment is to reduce acute phase symptoms and return the patient to their baseline level of functioning.
    • Many patients who have one episode of schizophrenia will go on to have further episodes and generally require maintenance treatment with antipsychotic drugs to prevent relapses.
    • Antipsychotic drugs are effective in treating acute schizophrenia episodes, as they are more effective at alleviating positive symptoms than negative symptoms.
    • An oral antipsychotic drug in combination with psychological therapy should be offered to patients with schizophrenia, considering factors such as potential extrapyramidal symptoms, cardiovascular adverse effects, metabolic adverse effects, hormonal adverse effects, and patient and carer preference.
    • Treatment with an antipsychotic drug should be considered an explicit individual therapeutic trial.
    • Long-acting depot injectable antipsychotic drugs can be considered for patients with psychosis and schizophrenia where it is a clinical priority to avoid non-adherence.
    • First-generation antipsychotic drugs act predominantly by blocking dopamine D2 receptors in the brain, causing a range of side-effects, particularly acute extrapyramidal symptoms and hyperprolactinaemia.
    • Second-generation antipsychotic drugs act on a range of receptors and are generally associated with a lower risk for acute extrapyramidal symptoms and tardive dyskinesia.
    • Prescribing high-dose antipsychotic drugs is crucial, as there is no robust evidence that high doses of antipsychotic drug treatment are more effective than standard doses for the treatment of schizophrenia.
    • The majority of adverse effects associated with antipsychotic treatment are dose-related, and there is clear evidence for a greater side-effect burden with high-dose antipsychotic drug use.
    • Antipsychotic polypharmacy and 'when required' antipsychotic drug treatment are strongly associated with high-dose prescribing.
    • When prescribing an antipsychotic drug for administration in an emergency situation, the aim is to calm and sedate the patient without inducing sleep.
    • Prescribing antipsychotic drugs for elderly patients should balance risk and benefit, as they are associated with a small increased risk of mortality and an increased risk of stroke or transient ischaemic attack.
    • It is recommended that antipsychotic drugs should not be used in elderly patients with dementia unless they are at risk of harming themselves or others, experiencing agitation, hallucinations, or delusions that are causing severe distress.
    • In patients with learning disabilities who are taking antipsychotic drugs and not experiencing psychotic symptoms, considerations should be taken into account, including a reduction in dose or discontinuation of long-term antipsychotic treatment.

    Extrapyramidal Symptoms

    • Extrapyramidal symptoms are dose-related and are most likely to occur with high doses of first-generation antipsychotic drugs.
    • Extrapyramidal symptoms include parkinsonian symptoms, dystonia, akathisia, and tardive dyskinesia.
    • When parkinsonian symptoms are identified, treatment should be reviewed to reduce exposure to high-dose and high-potency antipsychotic drugs.
    • Antimuscarinic drugs can relieve symptom burden, but they should not be routinely prescribed for prophylaxis with antipsychotic drugs.
    • Tardive dyskinesia is the most serious manifestation of late-onset extrapyramidal symptoms and occurs more commonly in elderly females.
    • Antipsychotic treatment should be carefully and regularly reviewed, with changes to dose or drug made gradually over weeks or months to minimize the risk of withdrawal tardive dyskinesia.

    Hyperprolactinaemia

    • Hyperprolactinaemia is a common side effect of antipsychotic medication, with most first- and second-generation drugs increasing prolactin concentration due to dopamine inhibition.
    • Clinical symptoms of hyperprolactinaemia include sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea, and a possible increased risk of breast cancer.

    Sexual Dysfunction

    • Sexual dysfunction is reported as a side effect of all antipsychotic medication, with physical illness, psychiatric illness, and substance misuse contributing factors.
    • Antipsychotic-induced sexual dysfunction is caused by multiple mechanisms, including reduced dopamine transmission and hyperprolactinaemia, antimuscarinic effects, and alpha1-adrenoceptor antagonists.
    • The lowest risk of sexual dysfunction is found in aripiprazole and quetiapine.

    Cardiovascular Side-Effects

    • Cardiovascular side-effects of antipsychotic drugs include tachycardia, arrhythmias, and hypotension.
    • QT-interval prolongation is a particular concern with pimozide, and there is a higher probability of QT-interval prolongation in patients using any intravenous antipsychotic drug or combination of antipsychotic drugs with doses exceeding the recommended maximum.
    • Postural hypotension is a common cardiac side-effect of antipsychotic drugs, often presenting during initial dose titration.
    • Second-generation antipsychotics are most likely to cause postural hypotension, with slow dose titration being commonly used to minimize it.

    Diabetes and Weight Gain

    • Schizophrenia is associated with insulin resistance and diabetes, with the risk of diabetes increased in all patients with schizophrenia who take antipsychotic drugs.
    • Some evidence suggests that first-generation antipsychotic drugs are less likely to cause diabetes than second-generation drugs.
    • Amisulpride and aripiprazole have the lowest risk of diabetes of second-generation antipsychotic drugs.
    • Weight gain is another common side-effect of antipsychotic drugs, with clozapine and olanzapine commonly causing weight gain.
    • Amisulpride, asenapine, aripiprazole, cariprazine, haloperidol, lurasidone hydrochloride, sulpiride, and trifluoperazine are least likely to cause weight gain.

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