719 final Flashcards
Diabetic peripheral neuropathy is caused by
inflammation or damage in the periphery combined with central disturbance in pain processing.
Meperidine
a potent serotonin reuptake inhibitor and should not be given with MAOIs
Mechanism & cause for “wide spread pain”:
“Suprasegmental” central sensitization is hypothesized to be linked to plastic changes that occur in brain sites within the nociceptive pathway, especially the thalamus and cortex, in the presence of known peripheral causes or even in the absence of identifiable triggering events (ex. wide spread pain). In the case of peripherally activated suprasegmental central sensitization, it it as though the brain “learns” from its experience of pain, and decides not only to keep the process going, but also to enhance it and make it permanent. In the case of pain that originates centrally without peripheral input, it is as though the brain has figured out how to spontaneously activate its pain pathways. Conditions hypothesized to be caused by suprasegmental central sensitization syndromes of pain originating tin the brain without peripheral pain input include fibromyalgia, the syndrome of chronic widespread pain, and painful physical Sx of depression and anxiety Dos, especially PTSD.
Mechanism & cause for diabetic peripheral neuropathy:
Neuropathic pain arises from damage to, or dysfunction of, any part of the peripheral or central nervous system, whereas “normal” pain is caused by activation of nociceptive nerve fibers. Peripheral mechanisms in neuropathic pain Normal transduction and conduction in peripheral afferent neurons can be hijacked in certain neuropathic pain states to maintain nociceptive signaling in the absence of a relevant noxious stimulus. Neuronal damage by disease or trauma can alter electrical activity of neurons, allow cross-talk btw neurons, and initiate inflammatory processes to cause peripheral sensitization.
SSRIs may have
inconsistent effects on pain because serotonin can both inhibit and facilitate ascending nociceptive signals.
Milnacipran
can alleviate physical pain (fibromyalgia) and has potential effect on cognitive functioning.
Duloxetine
can treat both chronic pain and depression without significant side effects.
Zolpidem
Ambien. Non-benzo hypnotic.
Short-term Tx of insomnia (controlled-release indication is not restricted to short-term)
As needed for the Tx of insomnia when a middle-of-the-night awakening is followed by difficulty returning to sleep and there are at least 4 hours of bedtime remaining before the planned time of wakening (Intermezzo)
Zolpidem dose
10 mg/day at bedtime for 7–10 days (immediate), 12.5 mg/day (controlled)
Zaleplon
Sonata. Non-benzo hypnotic.
Short-term Tx of insomnia
Zaleplon dose
10 mg/day at bedtime for 7–10 days
Flurazepam
Dalmane. Benzo (hypnotic).
Insomnia characterized by difficulty in falling asleep, frequent nocturnal awakenings, and/or early morning awakening
Recurring insomnia or poor sleeping habits /Acute or chronic medical situations requiring restful sleep
Temazepam
Restoril. Benzo (hypnotic).
Short-term treatment of insomnia
All of these medications are schedule
IV
Sertraline and zolpidem
Sertraline increases plasma levels of zolpidem
A 72-year-old woman has difficulty falling asleep and frequent nighttime awakenings. The best medicine for her is
zolpidem
Eszopiclone
Lunesta.
approved for insomnia without S/E of tolerance/dependence.
the mechanism to treat insomnia with the least amount of psychomotor impairment.
Melatonin receptor stimulation
DSM-5 Dx for ADHD
(Sx in two or more settings)
· Inattention: 6 Sx have persisted for at least 6 months (5 Sx for over age 17)
· 1. Often fails to give close attention to details or makes careless mistakes 2. Often has difficulty sustaining attention in tasks or play activities 3. Often does not seem to listen when spoken to directly 4. Often has difficulty organizing tasks and activities 6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort 7. Often loses things necessary for tasks or activities 8. Is often distracted by extraneous stimuli 9. Is often forgetful in daily activities
Hyperactivity and impulsivity Dx
6 Sx for at least 6 months (5 Sx for over age 17)
· 1. Often fidgets with or taps hands or feet or squirms in seat 2. Often leaves seat in situations when remaining seated is expected 3. Often runs about or climbs in situations where it is inappropriate 4. Often unable to play or engage in leisure activities quietly 5. Is often “on the go,” acting as if “driven by a motor” 6. Often talks excessively 7. Often blurts out an answer before a question has been completed 8. Often has difficulty waiting his or her turn 9. Often interrupts or intrudes on others
· The age threshold for diagnosing ADHD changed from 7 to 12 years old.
Sustained attention is hypothetically modulated by the
cortico-striatal-thalamic-cortical loop involving the dorsolateral prefrontal cortex (DLPFC)
Amphetamine (Dexedrine)
stimulant (Schedule II)
ADHD (6 or 3 depending on formula), Narcolepsy (12 or 6)
Amphetamine (Adderall)
stimulant (Schedule II)
ADHD ages 3–12 (Adderall, Evekeo),
ADHD ages 6–17 (Adderall XR, Evekeo, Dyanavel XR, Adzenys XR-ODT)
and in adults (Adderall XR, Evekeo, Adzenys XR-ODT), Narcolepsy (Adderall, Evekeo),
Exogenous obesity (Evekeo)
Lisdexamfetamine
Vyvanse stimulant (Schedule II)
ADHD age 6, Binge eating disorder
Atomoxetine
(Strattera) Selective Norepinephrine Reuptake Inhibitor (NRI)
ADHD in adults and children 6
Guanfacine (Intuniv)
Hypertension, ADHD in children ages 6–17 (Intuniv, adjunct and monotherapy)
5 A’s
ask, Advise, Assess, Assist, and Arrange follow up
Ask about tobacco use
Identify & document tobacco use status of every pt at every visit.
Advise to quit
In a clear, strong & personalized manner urge every tobacco user to quit.
Assess
For current tobacco user, is the tobacco user willing to make a quit attempt at this time? For the ex-tobacco user, how recent did you quit and are there any challenges to remaining abstinent?
Assist
For the pt willing to make a quit attempt, offer med & provide or refer for counseling or additional behavioral Tx to help the pt quit. For pts unwilling to quit at this time, provide motivational interventions designed to increase future quit attempts. For the recent quitter & any with remaining challenges, provide relapse prevention.
Arrange
All those receiving the previous A’s should receive follow up
tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective Tx
exist, however, that can significantly increase rates of long-term abstinence.
tobacco dependence Tx are effective for
a broad range of populations.
Brief tobacco dependence Tx is
effective. Clinicians should offer every pt who uses tobacco at least the brief Tx shown to be effective in the Guideline.
individual, group, and telephone counseling are
effective and their effectiveness increases with Tx intensity
2 components of counseling are especially effective:
Practical counseling (problem-solving/skills training), Social support
Numerous effective meds for tobacco dependence and clinicians should encourage their use by all pts attempting to quit smoking, except when
medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, adolescents)
Recommended front-line meds: Seven 1st line meds
(5 nicotine & 2 non) reliably increase long-term smoking abstinence rates (Bupropion SR, Nicotine gum/inhaler/lozenge/nasal spray/patch, Varenicline)
Counseling and med are effective when used by themselves for treating tobacco dependence. However,
the combination of counseling and med is more effective than either alone
Telephone quit line counseling is
effective with diverse populations and has broad reach
If a tobacco user is currently unwilling to make a quit attempt, clinicians should
use the motivational Tx shown in the Guideline to be effective in increasing future quit attempts.
Tobacco dependence Tx are both clinically effective and highly
cost-effective
XR-Naltrexone by IM and advantages to choosing Naltrexone IM:
Adherence
Naltrexone
(Revia: oral, Vivitrol: injection)
FDA: Alcohol dependence, Blockade of effects of exogenously administered opioids (oral), Prevention of relapse to opioid dependence (injection)
Naltrexone contraindication
taking opioid analgesics /currently dependent on opioids or is in acute opiate withdrawal /failed the naloxone challenge test or a positive urine screen for opioids
/acute hepatitis or liver failure /proven allergy to naltrexone /proven allergy to polylactideco-glycolide (PLG), arboxymethylcellulose, or any other components of the diluent (injection)
Acamprosate
Campral
Maintenance of alcohol abstinence
Disulfiram
Antabuse
FDA: Maintenance of alcohol abstinence
3 drugs approved by the FDA to treat opioid dependence:
buprenorphine, methadone, and naltrexone
maximum recommended duration of buprenorphine, methadone, and naltrexone
no maximum
FDA-approved buprenorphine products for the Tx of opioid dependence include:
Bunavail (buprenorphine and naloxone) buccal film
/Cassipa (buprenorphine and naloxone) sublingual film
/Probuphine (buprenorphine) implant for subdermal administration /
Sublocade
Suboxone
Subutex (buprenorphine)
Zubsolv (buprenorphine and naloxone) sublingual tablets
· FDA-approved methadone products for the Tx of opioid dependence include:
Dolophine (methadone hydrochloride) tablets
Methadose (methadone hydrochloride) oral concentrate
FDA-approved naltrexone products for the Tx of opioid dependence include:
Vivitrol
opioid withdrawal syndrome is characterized by
the patient feeling dysphoria, craving another dose of opioid, being irritable, and having signs of autonomic hyperactivity such as tachycardia, tremor, and sweating. Pilo-erection (“goose-bumps”) is often associated with opioid withdrawal, especially when drug is stopped suddenly (“cold turkey”).
Opioid receptors can readapt to normal if
given a chance to do so in the absence of additional intake of an opioid (you don’t take opioids for a long time).
