A 50-year-old man develops chronic, severe pain after sustaining a brachial plexus injury as a result of motorbike accident. He has had no benefit from paracetamol or ibuprofen.
Following recent NICE guidelines, what is the most appropriate medication to consider?
Correct Answer D:
Neuropathic pain:
Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesia.
Examples include:
NICE issued guidance in 2010 on the management of neuropathic pain:
*Please note that for some specific conditions the guidance may vary. For example carbamazepine is used firstline for trigeminal neuralgia, duloxetine for diabetic neuropathy.
A 24-year-old woman presents for advice. Over the past few months she has been having increasing problems with migraine around the time of menstruation. Her current migraine started around 24 hours ago and has not responded to a combination of paracetamol and aspirin.
What is the most appropriate next step to relieve her headache?
Correct Answer C: Oral mefanamic acid would also be a suitable alternative.
Migraine: pregnancy, contraception and other hormonal factors:
SIGN produced guidelines in 2008 on the management of migraine, the following is selected highlights:
Migraine during pregnancy:
Migraine and the combined oral contraceptive (COC) pill:
Migraine and menstruation:
Migraine and hormone replacement therapy (HRT):
A 71-year-old man is reviewed following an ischaemic stroke. He is known to be intolerant of clopidogrel.
What is the most appropriate therapy to help reduce his chance of having a further stroke?
Correct Answer E: Please see the 2010 NICE guidelines for more details. The 2-year limit has now been removed.
Stroke: management:
The Royal College of Physicians (RCP) published guidelines on the diagnosis and management of patients following a stroke in 2004. NICE also issued stroke guidelines in 2008, although they modified their guidance with respect to antiplatelet therapy in 2010.
Selected points relating to the management of acute stroke include:
Thrombolysis:
Thrombolysis should only be given if:
Secondary prevention: NICE also published a technology appraisal in 2010 on the use of clopidogrel and dipyridamole Recommendations from NICE include:
With regards to carotid artery endarterectomy:
*the 2009 Controlling hypertension and hypotension immediately post-stroke (CHHIPS) trial may change thinking on this but guidelines have yet to change to reflect this
**SIGN recommend a window of 4.5 hours
***European Carotid Surgery Trialists' Collaborative Group
****North American Symptomatic Carotid Endarterectomy Trial
Antiepileptic medication is known to increase the risk of congenital defects.
Which one of the following medications is thought to be associated with the lowest risk?
Epilepsy: pregnancy and breast feeding: The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus. All women thinking about becoming pregnant should be advised to take folic acid 5mg per day well before pregnancy to minimize the risk of neural tube defects. Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication.
Other points:
Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates.
It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.
You review a 65-year-old man who is currently taking antipsychotic medication. His carers have noticed that his movements have been very slow over the past few weeks.
Which one of the following would suggest a diagnosis of Parkinson's disease rather than drug-induced parkinsonism?
Correct Answer A: Rigidity and rest tremor are uncommon in drug-induced parkinsonism. Masked face and flexed posture can be seen in both conditions. Bilateral symptoms are more common in drug-induced parkinsonism. Restlessness of arms and legs (akathisia) is a common side-effect of antipsychotics.
Parkinson's disease: features:
Parkinson's disease is a progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra.. This results in a classic triad of features: bradykinesia, tremor and rigidity. The symptoms of Parkinson's disease are characteristically asymmetrical.
Bradykinesia:
Rigidity:
Other characteristic features:
Drug-induced parkinsonism has slightly different features to Parkinson's disease:
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