58. Alzheimer's Disease Flashcards
A patient with dementia has nausea whenever he uses his rivastigmine medication. His wife asks the pharmacist for assistance. What medication would be useful to reduce the nausea? (Select ALL that apply.)
A. The Exelon patch
B. Memantine ODT
C. Galantamine ODT
D. The tacrine patch
E. Aricept ODT
A, E. Nausea (and rarely vomiting) are the primary side effects of the acetylcholinesterase inhibitors. Rivastigmine comes in a patch formulation. It is the only acetylcholinesterase inhibitor that is available in a patch formulation. Longer-acting formulations generally reduce nausea. In addition, the patch bypasses the oral route. Aricept is available in an ODT formulation.
Select the mechanism of action of donepezil:
A. Decarboxylase inhibitor
B. Norepinephrine reuptake inhibitor
C. Acetylcholinesterase Inhibitor
D. Anticholinergic
E. NMDA-receptor antagonist
C. Donepezil is an acetylcholinesterase inhibitor.
A caregiver is picking up a new prescription of Namenda for her patient. The pharmacist will counsel the caregiver on this medication. Which of the following statements are correct? (Select ALL that apply.)
A. This medication comes in different forms, such as a capsule and an oral solution, which may be easier to administer.
B. This medication can be taken with or without food.
C. If there is any difficulty swallowing the extended-release capsule, you can open it and sprinkle the contents on applesauce.
D. The common side effects are headache, racing heart and shortness of breath.
E. This medication can reverse the symptoms of memory loss if taken regularly.
A, B, C. Unfortunately, the medications used for dementia offer little (very mild) benefit. Possible side effects of Namenda include dizziness, constipation (and in some patients, diarrhea), and headache.
A patient gave the pharmacist a prescription for Razadyne ER 8 mg once daily #30. Which of the following is an appropriate generic substitution for Razadyne?
A. Tacrine
B. Cognex
C. Rivastigmine
D. Galantamine
E. Memantine
D. The generic name of Razadyne is galantamine.
Why are patients instructed to take donepezil in the evening?
A. Donepezil is activating.
B. Donepezil is sedating.
C. Donepezil causes nausea.
D. Donepezil causes urinary retention.
E. Donepezil can be taken at any time; it doesn’t really matter.
C. Due to nausea and generalized stomach upset, patients are often instructed to take donepezil in the evening so they can “sleep through” the stomach upset. This may make it easier for them to eat during the day. This is unusual; most of the time, when medications are taken at bedtime, it is because the drug is sedating (but also must last long enough to be dosed just once/24 hours).
Andy is a 70 year-old male with difficulty falling asleep. He went to the pharmacy and purchased diphenhydramine. What possible side effect might Andy experience from the use of this medicine?
A. Diarrhea
B. Urinary frequency
C. Confusion
D. Excessive tearing
E. Excessive saliva and drooling
C. Diphenhydramine and other first generation antihistamines (along with centrally-acting anticholinergics, which have a similar side effect profile) are considered “Do Not Use Drugs in the Elderly” due to the high incidence of both peripheral and central anticholinergic side effects.
Which of the following agents used for dementia should be taken with food regardless of whether GI side effects are present?
A. Aricept
B. Razadyne
C. Exelon
D. Namenda
E. Ginkgo biloba
C. The other agents are with food or without food. If nausea is present food can be used to lessen the nausea.
Select the indications for the use of donepezil: (Select ALL that apply.)
A. For mild-to-severe Alzheimer’s Disease
B. For wearing off associated with rivastigmine therapy
C. For moderate to-severe disease in combination with memantine
D. For wearing off associated with galantamine therapy
E. For moderate to-severe disease in combination with rivastigmine
A, C. Although the indication has been expanded, there is mild benefit with these agents. Donepezil is indicated for treatment of mild, moderate, or severe dementia of the Alzheimer’s type, and can be used in combination with memantine.
Select the mechanism of action of memantine:
A. Decarboxylase inhibitor
B. Norepinephrine reuptake inhibitor
C. Adrenergic
D. Anticholinergic
E. NMDA-receptor antagonist
E. Memantine is an NMDA receptor blocker, used in more advanced disease. It is often given in combination with donepezil.
A patient receives a score of 20 on an MMSE. Which medication is likely to be initiated?
A. Levodopa-carbidopa
B. Trihexyphenidyl
C. Donepezil
D. Entacapone
E. Darifenacin
C. The Mini-Mental State Examination (MMSE) scoring ranges from 0 to 30 points and is used to assess cognitive impairment. A score below 24 indicates impairment and would be used to justify treatment with a drug such as donepezil.
A patient gave the pharmacist a prescription for Namenda 5 mg twice daily #60. Which of the following is an appropriate generic substitution for Namenda?
A. Memantine
B. Aricept
C. Cognex
D. Tacrine
E. Razadyne
A. The generic name of Namenda is memantine.
A patient will begin therapy with the Exelon patch. Which of the following are correct counseling statements? (Select ALLthat apply.)
A. Apply the patch once weekly; choose a day of the week that it is easy to remember.
B. Apply on the back, upper arm or chest, and always change the site from day-to-day so that the skin does not become irritated.
C. Prior to applying the patch, lubricate the skin well to reduce the risk of irritation with a product such as Cetaphilor Lubriderm.
D. Remove the patch prior to an MRI procedure or your skin will burn.
E. Remove the protective liner from one side of the patch, and place the sticky side on your skin, then remove the second side of the liner.
B, E. The patches are applied daily (30 patches/box). If patches are put on skin that has just had lubricant applied the patch will not stick well. The Exelon patch does not need to be removed prior to an MRI as it does not contain metal, however the MRI tech will probably instruct patients to remove all patches in order to be on the safe side; they do not know for sure what type of patch the patient is using and do not wish to risk a burn.
A patient gave the pharmacist a prescription for Exelon 1.5 mg BID #60. Which of the following is an appropriate generic substitution for Exelon?
A. Tacrine
B. Donepezil
C. Rivastigmine
D. Galantamine
E. Memantine
C. The generic name of Exelon is rivastigmine.
Sam is a 79 year-old male who has been using rivastigmine for one year. His wife reports that it initially was helpful. Now, she is not sure. She states Sam is forgetful to the point that he cannot remember the grandchildren’s names. She has asked the physician for a stronger medicine. She presents to the pharmacy with a prescription for memantine. Choose the correct statement regarding memantine:
A. The brand name is Exelon.
B. The brand name is Comtan.
C. Memantine is dosed initially at 20 mg PO QHS.
D. Memantine is approved for moderate-severe disease
E. Memantine causes significant GI side effects and should be taken with food.
D. Memantine is an NMDA receptor antagonist (which is where the brand name came from), approved for use alone or in combination with donepezil for moderate-severe dementia of the Alzheimer’s type. The starting dose of memantine is 5 mg once daily.
Mason is a 75 year-old African American male who had a stroke 12 months ago. His other medical conditions include heart failure and mild memory impairment. Mason’s medications include clopidogrel, aspirin, an ACE inhibitor, a beta blocker (Toprol XL), a loop diuretic (Bumex), potassium, Aleve and ginkgo biloba. He presents to the emergency room with blood coming from his penis and a nosebleed. Choose the agents that Mason is taking that can increase the risk of bleeding: (Select ALL that apply.)
A. Ginkgo biloba
B. Clopidogrel
C. Aspirin
D. Bumex
E. Aleve
A, B, C, E. Ginkgo is commonly used for memory impairment and is the natural product with the highest risk for bleeding. It must be stopped well in advance of any elective surgery. Keep in mind that the patient population which uses ginkgo for memory impairment are elderly patients-the same group that is often using prescription anticoagulants and/or antiplatelets. In this case, the risk for bleeding is additive and can become dangerous.
