10] Pharmacology Flashcards
1
Q
Most common form of ischemic stroke
A
Embolic
2
Q
Slow, cautious behavior
A
L CVA
3
Q
Left sided neglect
A
R CVA
4
Q
Most fatal stroke
A
Hemorrhagic
5
Q
No clinically proven pharmacological intervention exists
A
Hemorrhagic stroke
6
Q
What’s an important predictor of outcome?
A
Clot volume
7
Q
Less common stroke symptoms
A
Nausea and vomiting
LOC
Convulsions
8
Q
What does FAST stand for?
A
Face
Arm
Speech
Time
9
Q
Irregularly irregular rhythm
A
A fib
10
Q
Increased risk in pts with HTN, HF, or lung disease
A
A fib
11
Q
How does a fib cause a stroke?
A
Unorganized flow so theres blood pool in atria and creates a clot in the atria then travels thru bloodstream to the head and blocks an artery causing a STROKE
12
Q
Pharm for hemorrhagic stroke?
A
Surgery/interventions
13
Q
Pharm care for ischemic stroke?
A
Drug therapy
14
Q
TX goals
A
Reduce current injury
Prevent complications
Prevent stroke recurrence
15
Q
Drugs for early stroke care
A
1] TPA (tissue plasminogen activator)
2] antiplatelets
3] anticoagulants
16
Q
Dissolves arterial clots
A
TPA (alteplase)
17
Q
Decreases risk of long term neuro deficit
A
TPA
18
Q
When does TPA have to be used?
A
Within 3 hours of stroke Sx, recent studies said within 4.5 hour
19
Q
Side effects of altepase
A
Bleeding Cerebral edema Seizure Hypotension Fever
20
Q
Exclusion criteria for tPA
A
Hemorrhagic stroke; b/c it has to be ischemic
21
Q
PT after tPA treatment
A
Rest for 24 hours
Early mobilization is safe and feasible less than 24 hours
22
Q
Tool used to predict stroke risk in pts with a fib
A
CHADsVasc score
23
Q
CHADsVasc score is used to guide selection of?
A
Antiplatelet/anticoagulant therapy
24
Q
Scoring of CHAD
A
0, 1, 2 or greater
25
1 point on CHAD
Moderate; no Tx or aspirin or oral anticoagulant, up to you.
26
Score of 2 or greater on CHAD
High; oral anticoagulant
27
Common 3 antiplatelets
Aspirin
Clopidogrel (placid)
Dipyridamole/aspirin (aggrenox)
28
Started within 48 hours of stroke; A fib with moderate risk
Aspirin
29
Inhibits the enzyme cyclooxygenase to reduce production of thromboxane A2
Aspirin
30
Side effects of aspirin
Bleeding
GI ulcer
Anemia
Nausea
31
Contraindications: asthma, rhinitis, nasal polyps, NSAID allergy
Aspirin
32
Dont use aspirin within ?
24 hours of alteplase
33
Avoid aspirin in?
Severe renal or hepatic impairments
34
Aspirin over the counter?
YES
35
Caution with what allergy for aspirin?
NSAID allergy
36
What’s the standard of care Tx for antiplatelets?
Aspirin
37
Initiated after a thrombotic stroke
Clopidogrel (plavix)
38
Blocks P2Y12 components on ADP receptors
Plavix
39
Side effects of plavix
```
Bleeding
Bruising
Itching
Diarrhea
Rash (first 2 weeks)
```
40
Common drug interaction for plavix
Omeprazole
41
Grapefruit juice
More than 1 cup no good with taking plavix
42
Some people have an allele that can play a role in how this drug works
Plavix
43
Prescription only drug
Dipyridamole/aspirin (aggrenox)
44
Used in secondary prevention of stroke
Aggrenox
45
Inhibits phosphodiesterase and augments prostacyclin related platelet aggregation
Aggrenox
46
Side effects of aggrenox
```
Bleeding
Bruising
Headache
GI upset
Fatigue
```
47
With antiplatelets what should you caution?
Increased risk of bleeding
48
What’s stronger than antiplatelets?
Anticoagulants
49
avoid alcohol due to increased bleeding risk
Aggrenox
50
Only available in capsules that have to be swallowed whole
Aggrenox
51
Ultimate goal of coagulation cascade
Conversion from pro thrombin to thrombin
52
Warfarin
Dabigatran
Rivaroxaban
Apixaban
Oral anticoagulants
53
Enoxaparin
Fondapurinux
Dalteparin
Heparin
Injectable anticoagulants
54
Warfarin is aka
Coumadin
55
Inhibits the vitamin K dependent synthesis of clotting factors
Warfarin
56
Side effects of warfarin
```
Bleeding
Bruising
Skin necrosis
“Purple toe syndrome”
Hemorrhage
```
57
T or F: warfarin has many drug interactions
TRUE
58
Hemorrhagic tendencies (active GI/CNS bleed), pregnancy
Contraindications of warfarin
59
Requires therapeutic monitoring of INR, can be started 24 hours post stroke
Warfarin
60
Must have consistent what with warfarin?
Must have consistent vitamin K
61
Pregnancy category for warfarin
X
62
What beverages increase bleeding risk with warfarin?
Alcohol
| Cranberry juice
63
What does INR tell you?
How thick/thin blood is
64
Average INR ?
1
65
Therapeutic range for INR?
Between 2-3
66
Therapeutic range of INR for mitral valve replacement?
2.5 - 3.5
67
DOACs
Direct acting oral anticoagulants
68
2 types of DOACs
Factor Xa inhibitors
| Rectus thrombin inhibitors
69
Example of direct thrombin inhibitor
Dabigatran
70
Started within 2-14 days after onset of stroke;
| Started immediately for A fib
DOAC
71
Side effects of DOAC
```
Bleeding
Bruising
Headache
Ab pain
Diarrhea
Heartburn
Nausea
Tinnitus
```
72
Anticoagulants
NSAID
St. John’s wort
Protesting
DOAC drug interaction, avoid!!
73
Contraindication for DOAC
Active pathological bleeding
74
Pregnancy category for DOAC
B - C
75
DOACs are primarily metabolized by?
Kidneys
76
Pros of DOACs
Don’t require routine monitoring
| No diet restrictions
77
Cons of DOACs
Less clinical experience
Cost
No antidote (except for dabigatran)
78
Includes variety of medication that inhibit synthesis and function of clotting factors (thrombin, IXa, Xa)
Heparin
79
2 types of LMWH
Enoxaparin
| Dalteparin
80
2 types of heparin
UFH (unfractionates heparin)
| LMWH
81
•Used to prevent or treat deep vein thrombosis (DVT)following stroke
Heparin
82
Inhibit synthesis and function of clotting factors (thrombin, IXa, Xa)
MoA for heparin
83
Bleeding, osteoporosis (chronic therapy), hemorrhage,heparin-induced thrombocytopenia (HIT)
Side effects for heparin
84
Anticoagulants, estrogen derivatives, NSAIDs
Drug interactions for heparin
85
Severe thrombocytopenia or history of HIT, uncontrolledactive bleeding, pork products (LMWH)
Contraindications for heparin
86
Clinical consideration for heparin
Subcutaneous administration
87
Pregnancy category for heparin
B - C
88
Low-dose aspirin may be given up to ?
The day of procedure
89
Ibuprofen, naproxen, diclofenac, indomethacin
NSAIDs that are NOT recommended for pain with anticoagulants
90
What is recommended for ppl who have pain with antocoagulation?
Acetaminophen (Tylenol)
| Opioids
91
Used for moderate to severe pain with anticoagulation
Opioids
92
The primary side effects from anticoagulants involves ?
Bleeding and bruising
93
? requires strict dietary considerations to maintain appropriate monitoring levels
Warfarin
94
? should not be recommended for pain management in patients on anticoagulants (acetaminophen and opioids better option)
NSAIDs
95
Are anticoagulants and antiplatelets used together?
Yes sometimes like warfarin and aspirin
96
When would you use combo of antis?
Pt on warfarin but they still have clot. This is very short term.
97
Avoid drugs that increase risk of bleeding like? (3)
NSAIDs
Antidepressants
Herbals
98
* Avoid drugs that increase risk of bleeding
* Avoid alcohol
* Avoid contact sports
* Wear properly fitted shoes
* Avoid drugs that can cause dizziness
Decrease bleeding risk
99
Pain in back, abdomen, or joints may indicate ?
Internal bleeding
100
Secondary stroke prevention
1] anticoag and antiplatelets therapy
2] blood pressure reduction
3] cholesterol management
4] lifestyle changes
101
Post stroke spasticity signs
```
Flexed elbow
Bent wrist
Pronated forearm
Clenched fist
Thumb in palm
```
102
Occurs in 65% of patients post-stroke
| In
Spasticity
103
Characterized by increased muscle tone
Spasticity
104
Baclofen
• Diazepam
• Tizanidine
Centrally acting agents for spasticity
105
Peripherally acting agent for spasticity
Don’t role even
106
More effective in treating spasticity resulting from spinal cord lesions
Baclofen (Lioresal®)
107
Agonizes GABA-b receptors at the spinal cord
MoA for baclofen
108
Transient drowsiness, confusion, hallucinations, fatigue,nausea/vomiting, muscle weakness, and headache
Side effects for baclofen
109
Opioids, zolpidem, azelastine (nasal), buprenorphine
Drug interactions for baclofen
110
Effectiveness is limited by systemic side effects
Baclofen
111
Limited ability to cross the blood brain barrier
Baclofen
112
May lower seizure threshold
Baclofen
113
Withdrawal symptoms with abrupt discontinuation
Baclofen
114
Severe, intractable spasticity
unresponsive to oral agents
• Intolerable side effects at effective oraldoses
Indications for intrathecal baclofen
115
Black box warning for intrathecal baclofen
Abrupt discontinuation may lead to organ failure or death
116
Disruption in the delivery system
• Infection
• Dislodged pump or a blocked or twisted catheter
• Pump failure leading to overdose
Complications for intrathecal baclofen
117
Is intrathecal baclofen expensive?
$$$ yep.
118
Spasticity resulting from cord lesions
Diazepam
119
Side effects of diazepam
Sedation, decreased walking speed, muscle weakness, hypotension, ataxia, constipation
120
Opioids, zolpidem, azelastine (nasal), buprenorphine, St. John’s Wort
Drug interaction for diazepam
121
Acute narrow-angle or untreated open-angle glaucoma, myasthenia gravis, severe hepatic or respiratory impairment, sleep apnea
Contraindications for diazepam
122
Class IV controlled substance
Long half-life; not recommended in elderlyAvoid alcohol
Tolerance and dependence can develop
Clinical considerations for diazepam
123
Pregnancy category for diazepam
D
124
Spasticity due to cerebral lesions
Tizanidine
125
MoA for tizanidine
Binds to alpha 2 adrenergic receptors in CNS and stimulates them
126
Sedation, dizziness, hypotension, dry mouth, hepatotoxicity
Side effects of tizanidine
127
Ciprofloxacin, opiods, azelastine, zolpidem, tricyclic antidepressants
Drug interaction for tizanidine
128
Contraindication for tizanidine
Concomitant therapy with ciprofloxacin or fluvoxamine
129
Avoid tizanidine in what kind of patients?
Liver disease patients
130
Withdrawal symptoms upon abrupt discontinuation
Clinical consideration for tizanidine
131
Pregnancy category for tizanidine
C
132
Spasticity that limits rehabilitation progression, or severe spasticity
Dantrolene
133
Directly acts on skeletal muscle, interfering with calcium stores
MoA for dantrolene
134
Generalized muscle weakness, drowsiness, hepatotoxicity, dizziness, nausea/diarrhea
Dantrolene side effects
135
Opioids, zolpidem, azelastine (nasal), buprenorphine, St. John’s Wort
Drug interactions for dantrolene
136
Black box warning for dantrolene
Hepatic disease
137
Less cognitive side effects- clinical consideration
Dantrolene
138
Pregnancy category for dantrolene
C
139
Approved for upper limb spasticity
Botulinum toxin
140
Recommended in patients with painful spasticity that limits skin hygiene and
daily functioning
Bot tox
141
Effects of bot tox
Decreased muscle tone
| Increased ROM
142
Black box warning for bot tox
Injected toxins may
spread to distal sites
and cause symptoms of botulism (potentially
fatal)
143
```
Fatigue
• Nausea
• Bronchitis
• Pain at injection site
• Weakness
```
Side effects of bot tox
144
Very effective for severe spasticity and focal dystonias
Pro of bot tox
145
Can be used in conjunction with PT toimprove voluntary motor function
Pro of bot tox
146
Treatment limited to 1-2 muscle
groups/session
Effects are often temporary (2-3 months)Not a cure
Cons of bot tox
147
? used to treat spasticity that occurs followinglesions in the CNS
Muscle relaxants
148
Most are easily absorbed from the GI tract, and oral route isfrequently used (other routes available)
Muscle relaxants
149
Long-term use is not optimal given side effect profile (especially sedation!)
Muscle relaxants
150
Concomitant use with physical therapy can produce optimalbenefits
Muscle relaxants
