06 Neurology Williams Flashcards
What are the Dopamine Agonists used for Parkinson Disease?
Bromocriptine. Pramipexole. Ropinirole. Apomorphine. Rotigotine
What is Multiple Sclerosis (MS)?
A chronic inflammatory and degenerative disease of the CNS in which destruction of oligodendrocytes leads to demyelination of neurons. Mean age of onset: 30 years
What are the 3 mains types of MS?
Relapsing-Remitting MS (80-90% when 1st diagnosed). Secondary-Progressive MS. Primary-Progressive MS
What are the first line agents used in MS?
Interferon Beta 1a (Avonex or Rebif). Interferon Beta 1b (Betaseron or Extavia). Flingolimod (Gilenya). Glatiramer (Copaxone)
What are the common ADRs when using Interferon Beta for MS?
Depression, flu-like symptoms, injection site reactions, liver injury
When does Fingolimod (Gilenya) for MS need to be avoided?
In patients with recent MI, angina, stroke, TIA, CHF. This drug causes bradycardia, increased BP, macular edema, and liver injury
What is Dimethyl Fumarate (Tecfidera) used for?
Relapsing MS. Dosed BID
What are the ADRs associated with Dimethyl Fumarate (Tecfidera)?
Dermatitis/irritation. Flushing (take w/ food, tolerance over time). GI (N/V/D). Hepatic effects (transaminase elevations)
What needs to be done when starting Dimethyl Fumarate (Tecfidera) to avoid Lymphopenia?
Baseline CCBC w/in 6 months prior to initiation. Obtain CBC annually. Mean lymphocyte decreased ~30% over the first year (then stabilized). Watch for patients having increased occurrance of infections
What is Teriflunomide (Aubagio) used for?
Relapsing MS. Taken PO QD
What is the MOA of Teriflunomide (Aubagio)?
Immunomodulatory agent that inhibits pyrimidine synthesis. Anti-proliferative and anti-inflammatory effects. May reduce the number of activated lymphocytes in the CNS
What is the BBW for Teriflunomide (Aubagio)?
Hepatotoxicity (do not administer in patients w/ chronic liver disease, or impairment. Discontinue if ALT > 3x ULN and start drug elimination procedures). Pregnancy/Teratogenicity (need two levels < 0.02mg/L, 14 days apart prior to becoming pregnant)
What is the drug elimination procedure for Teriflunomide (Aubagio)?
Cholestyramine 8mg Q8h x11 days (11 days do not need to be consecutive unless plasma concentrations need to be lowered rapidly). Activated charcoal 50mg Q12h x11 days. Both regimens are associated w/ > 98% decrease in concentrations
What are some common ADRs with Teriflunomide (Aubagio)?
Increased ALT. Alopecia. Diarrhea. Influenza. Nausea. HA. Hypophosphatemia
What are some counseling points for Teriflunomide (Aubagio)?
Up to date w/ all immunizations (avoid live vaccines). Use contraception at all times (both men and women). Can be taken w/ or w/o food
What is Dalfampridine (Ampyra)?
Nonspecific Potassium Channel Blocker. Used as treatment to improve walking in patients w/ MS. Dosed PO BID
What are the new warnings for Dalfampridine (Ampyra)?
Seizure (now CI in hx of seizure). Renal (now CI in CrCl < 50)
What does FAST stand for when talking about acute ischemic strokes?
F = Face. A = Arms. S = Speech. T = Time (call 911 immediately)
What general supportive care should be done after an acute ischemic stroke in regards to cardiac monitoring?
Cardiac monitoring for at least 1st 24 hours. BP < 185/110mmHg before Fibrinolytic treatment (if not receiving fibrinolytic, target < 220/120, lower BP by 15% in first 24 hrs. Can restart BP medications 24 hrs after stroke if patient neurologically stable)
What are some other general supportive things to do after an acute ischemic stroke?
Airway support, supplemental O2 (sat > 94%). Treat fevers. Hypovolemia corrected w/ IV NS. Correct hypoglycemia (glucose < 60) or hyperglycemia (Glucose > 180). Seizures: treat w/ antiepileptic (prophylaxis not recommended)
When is intravenous Fibrinolysis (rtPA) recommended?
For selected patients who may be treated w/in 3 hours of onset of ischemic stroke (0.9mg/kg, max dose 90mg, benefit is time dependent, door-to-needle time should be w/in 60min from hospital arrival)
What is the inclusion criteria for IV rtPA w/in 3 hours from symptoms?
Diagnosis of ischemic stroke causing measurable neurological deficit. Onset of symptoms < 3 hours before beginning treatment. Aged 18+ years
What is the exclusion criteria for IV rtPA w/in 3 hours from symptoms?
Significant head trauma or prior stroke in previous 3 months. Subarachnoid hemorrhage/hx of ICH. Elevated BP > 185/110mmHg. Active bleeding. Platelets < 100k. Heparin w/in 48 hrs, resulting in elevated aPTT. Anticoagulant w/ INR > 1.7 or PT > 15 seconds. Blood glucose < 50
What is the inclusion criteria for IV rtPA w/in 3 to 4.5 hours from symptoms?
Diagnosis of ischemic stroke causing measurable neurological deficit
What is the exclusion criteria for IV rtPA w/in 3 to 4.5 hours from symptoms?
Aged > 80 years. Severe stroke (NHSS > 25). Taking an oral anticoagulant regardless of INR. History of both diabetes AND prior ischemic stroke
How is tPA Alteplase dosed?
0.9mg/kg, max 90mg
What is Status Epilepticus?
5+ minutes of continuous clinical and/or electrographic seizure activity or recurrent seizure activity w/o recovery between seizures
What is treatment like for Status Epilepticus?
Should occur rapidly and continue sequentially until clinical seizures and electrographic seizures are halted
What are the treatment options for Status Epilepticus?
Benzos should be given as emergent initial therapy. Lorazepam is DOC for IV administration. Midazolam is DOC for IM administration. Rectal Diazepam can be given if no IV/IM available
What are urgent control AED therapy recommendations for status epilepticus?
IV Fosphenytoin/phentoin. Levetiracetam. Valproate sodium
What are the treatment options for Refractory SE?
Should consist of continuous infusion AEDs. Should be titrated to cessation of electrographic seizures or burst suppression. Period of 24-48 hours of electrographic control is recommended prior to slow withdrawal of continuous infusion AEDs
What is the first line treatment for resistant SE?
Midazolam (0.2mg/kg infused at 2mg/min)
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