All other topics Flashcards
What is necessary for a diagnosis of insomnia?
Impaired daytime functioning due to difficulty initiating sleep, maintaining sleep, or inability to return to sleep when adequate time and opportunity for sleep is provided
When is short term and long term insomnia separated?
Before or after ( 3x a week) 3 months
What drug classes can be used to treat insomnia?
- Benzos
- Non-benzodiazepine hypnotics
- Orexin receptor agonists
- Antihistamines
- Tricyclic antidepressants
What are risks of use of BZDs and no-BZD hypnotics in insomnia?
- Fetal malformation 1st trimester pregnancy
- Alcohol consumption= excessive sedation
- Renal or heaptic dz metabolic clearance
- Pulmonary dz as they are respiratory suppressants
- Nighttime decision makers as impair decision making abilities
- 75+ adverse effects
How long should treatment last of insomnia with hypnotics?
6-8 weeks then taper off
What are ADRs common to hypnotics?
- residual daytime sedation
- drowsiness
- Cognitive/CNS impairment
- Dependence
- Respiratory depression
What are the non-BZD hypnotic drugs?
- Lunesta
- Sonata
- Ambien
What non-BZD hypnotic has the longest 1/2 life?
Lunesta
What non-BZD is the only one available for long term use?
Lunesta
If taking other drugs that are CYP 3A4 inhibitors, what drug is recommended?
Sonata
if a patient has a hard time falling asleep what drug based on 1/2 life is preferred?
Sonata
What is the Lunesta specific ADR?
Altered taste
What non-BZD hypnotic(s) are associated w/ next day impairment?
Lunesta and Ambien
What drug is an Orexin receptor antagonist?
Suvorexant
What is similar between Suxorexant and lunesta?
- CS 4
- Next day impairment
- Prominent 3A4 substrate
What is different about Suroxetant and Lunesta?
Mechanism of action
What drug is a melatonin agonist?
Ramelteon
What are important factors about Ramelteon?
- Not a controlled substance
- Pt must take 30 minutes before sleep (assist with sleep onset)
What warnings/ caution are associated with Ramelteon?
- Reproductive hormone disturbances
- Depression
- CNS depression
What antidepressant can be used to treat insomnia?
Doxepin
What drugs can be used in restless leg syndrome if iron supplementation does not fix it?
- Gabapentin/ Pregabalin
- Pramipexole/ Ropinirole
What is the 1st line treatment for narcolepsy?
Modafinil/ Armodafanil
Unless there is a C/I what approach is to be taken in helping patients quit smoking?
Behavioral and pharmalogical therapy
What are the 5 A’s of tobacco use and smoking?
- Ask motivation to quit
- Advise most important factor for health now and in the future
- Assess determine patient willingness to quit
- Assist quit date, tell family, friends and coworkers to assist
- Arrange office F/U w/in week of quit date
What is the 6th A of tobacco use and smokign directed at pediatrics?
Anticipate, discuss avoidance early
What are the 3 pharm methods to quit smoking/ tobacco use?
- Nicotine replacement therapy
- Chantix
- Bupropion
What is the best approach to treat tobacco use by NRT?
Combo therapy: long term transdermal patch w/ short term formulation
What is dosing of NRT based on?
Number of cigarettes per day and timing of first cigarette
What is meant by chew and park?
NRT gum cannot be chewed continually otherwise GI upset, HA, hiccups, and mouth ulcers
What NRT product gives the best option to address behavior and sensory aspects?
Inhaler but can cause bronchospasm
What is different about Chantix vs. NRT therapy?
- Chantix start week before quitting
- NRT start use day of quitting
What safety issues may arise with the use of Chantix?
- Neuropsychiatric: Hostility, agaitation, SI
- CV risk those w/ CV dz
- Seizure risk
- CNS depression
What is similar about Chantix and Burpropion?
- Start before quit date
- taken for 12 weeks
What type of drug is preferred to treat most psych illness patients that smoke? Which D/O is C/I this drug?
- Bupropion
- Bipolar D/O
What drug regiment is best indicated for hospitalized smoking pts?
NRT
What treatment should be used in pregnant pts?
NRT or Bupropion w/ behavioral therapy
What classification is alcohol?
CNS depressant
What occurs when there is abrupt cessation of alcohol use?
CNS overactivity; chronic ETOH exposure induces insensitivity to GABA
What are minor ETOH withdrawal sx?
- Tremor
- Mild anxiety
- HA
- Insomnia
- Palpitations
What are severe ETOH withdrawal symptoms?
- Withdrawal seizures
- Withdrawal hallucinations
- Delirium Tremens
When is the typical onset of withdrawal seizures?
12-48 hours after last drink
What is dangerous about withdrawal seizures?
1/3 lead to delirium tremens
When is the onset of alcoholic hallucinations and when do they resolve?
- Onset w/in 12-24 hours from last drink
- Resolve w/in 24-48 hours
What kind of hallucinations are most common during alcoholic hallucinosis?
Visual
How does alcoholic hallucinosis differ from delirium tremens?
In alcoholic hallucinosis VS are normal and there is no global clouding of sensorium
What signs/sx can be experienced in delirium tremens?
- Hallucinations
- Disorientation
- Tachycardia
- HTN
- Fever
- Agitation
- Diaphoresis
- Cardiac abnormalities
What is the onset and duration for delirium tremens?
- Onset 48-96 hours from last drink
- Duration of up to 7 days
What are risk factors for delirium tremens?
- Hx sustained drinking
- Hx prior DT
- > 30 yo
- Significant w/drawal in presence of elevated BAC
- > Longer period (2days) last drink
What is the mortality risk associated w/ DTs?
5% mainly due to cardiac arrhythmia
What is hallmark sx control and supportive care?
- BZDs agitation and prevent progression
- IV fluids
- Nutritional supplementation
- Frequent clinical reassessment
What is given to DT patients to prevent Wernicke’s encephalopathy?
- Thiamine
- Glucose
What BZDs are preferred for DT tx?
- Lorazepam or Diazepam
- In case of advanced cirrhosis Lorazepam or Oxazepam
When hospitalizing pts that have Hx of seizures, DT, or prologned heavy drinking tx prophylactically with what?
Chlordiazepoxide
What score from the clinical institute withdrawal assessment from alcohol-revised is consistent with no detoxification needed?
<8
What score from the clinical institute withdrawal assessment from alcohol-revised is consistent with ambulatory detoxification needed?
8-15
What score from the clinical institute withdrawal assessment from alcohol-revised is consistent with inpatient detoxification needed?
> 15
What criteria must be met for a pt to undergo ambulatory detox?
- CIWA 8-15 no DT sx
- Able to take PO meds
- Reliable support monitor pt continuously 3-7 days
- Commit to daily medical visits
- No unstable medical or psychiatric conditions
- Not pregnant
- No concurrent other substance abuse
- No hx DTs or ETOH-related seizures
What are alternatives to BZDs in ambulatory detox?
Anticonvulsants Carbamazepine and Valproate
What other type of tx do these ambulatory detox pts receive?
-multivitamin
-Thiamine
-Folate
“banana bag”
What is required for alcohol tx?
Pts that are MOTIVATED to reduce alcohol consumption
What are the drugs for treating chronic ETOH?
Naltrexone, Antabuse, Campral
What are requirements of a patient using Naltrexone?
- Pt can not be taking opioids (MOA block mu receptor)
- C/I in acute heptatits or liver failure
What ADRs associated with Naltrexone use?
- Nausea
- HA
- Dizziness
What are options in Naltrexone use?
- Depot formulation (monthly)
- PO daily
What is advantageous about the use of Campral?
Safe for liver dysfunction pts
What are CIs for antabuse?
- Severe myocardial disease
- Psychosis
- Pregnant
- Nursing mothers
How does Antabuse work?
Causes unpleasant physiologic reactions when alcohol is consumed
What type of immunity is vaccine?
Active (takes 2 weeks)
What vaccinations are Subcutaneous?
- MMR
- Varicella
- Zoster
What are rules for giving SubQ vaccination?
- Use tricep
- 23-25 gauge, 5/8 needle
- pinch up skin and insert 45 degree angle
- Separate multi-injection >1 inch
What rules for giving IM injection?
- Use deltoid
- Long needle 22-25 gauage and 1-1.5 inch wide
- Insert needle 90 degrees
- Separate multi-injection >1 inch
Should live viruses and immune globulins be administered on the same day?
No
What is required of a practitioner in regard to vaccines?
- Provide pt with vaccination information statement prior to vaccine
- Report adverse events
What are examples of reportable events?
- Anaphylaxis shock w/in 7 days
- Encephalopathy, encephalitis, or seizures
What are the type of allergic reactions to vaccines?
- Immediate (w/in 1 hour IgE mediated)
- Delayed (several hours to days rarely IgE)
What specific drugs should be given to mothers prior to conception?
-Live attenuated (MMR & Varicella)
What drugs can be given to mothers during pregnancy?
Tdap and Influenza
When is Tdap/ Td recommended in adults?
- Tdap: once every pregnancy and one dose as an adult
- Td every 10 years
When is MMR given and how many times?
- 2 times
- 12 to 15 months & 4 to 6 years
When is varicella vaccination given?
Adults w/o evidence of immunity receive 2 doses
Herpes zoster immunization given?
Single dose 60+ regardless of whether prior episode
How many doses of HPV are given in males/females? Age ranges?
- 3 doses
- 11-26 yo
At what age are PPSV23 and PCV13 given?
1 dose each at 65+ or <65 w/ immunocompromising conditions including smoking!
How does alcohol progress through the brain?
Highest cortical structures to the lowest
What receptors does alcohol work on?
GABA-A Receptors (depressant)
What does rate of absorption change due to?
Food in the stomach
How much of alcohol is absorbed by the stomach? What organ absorbs the rest?
- 10%
- Small intestines
What short term effects does mairjuana cause?
- Distorted perception
- Problems w/ memory or learning
- Loss of coordination
- Trouble w/ thinking and problem solving
- Increased heart rate
What effects do marijuana cause on different organs?
- Lungs: similar to cigarettes burning and stinging of throat, mouth
- Brain: Hallucinations, delusions, impaired memory, and disorientation
- Heart: increased 20-50 BPM increasing risk of heart attack
What is cannaboid hyperemesis syndrome?
- Recurrent N/V
- Colicky abdominal pain
- Results from at least weekly use of marijuana
What effects do K2/ spice have?
- loss of control
- decreased pain sensitivity
- Agitation
- Pale skin
- Sweating
- Spastic movements
- Dysphoria
- Paranoia
What major effects does K2/spice have?
- Similar sx withdrawls to heroin withdrawls
- Worsen previously stable psychotic disorders
- Trigger chronic psychosis
- Cause myocardial infarction
What effects do opioids cause on different systems?
- PNS: reduce heart rate, BP, and respiration rate, constipation, dry mouth
- CNS: Drowsiness, Euphoria, delirium, disorientation, analgesia
- Withdrawl: sweating, anxiety, depression, crying, diarrhea, goose flesh, cramps, fever
What kind of effects do methamphetamine cause?
- Degeneration of dopamine terminals
- Cognitive effects
- Meth mouth (dental erosion)
What are consequences/ signs of meth abuse?
- Heart failure
- Cardiac hypertrophy
- Stroke
- Kidney failure
- Paranoia, delusions, hallucinations
- Premature aging
- Death from hyperthermia or dehydration
What effects on systems does cocaine cause?
- Systemic: increased HR, BP, vasoconstriction, and platelet aggregation
- CNS: Euphoria, hyperactivity, increased alertness, decreased appetite
- Withdrawal: Irritability, agitation, depression, insomnia, tremors, muscle pain, and drug cravings
What are long term effects of cocaine use?
- Decreased brain metabolism
- Cognitive impairments
- Heart attacks
- Stroke
- Psychosis
- Oral and skin necrosis
How does ecstasy work?
It promotoes serotonin release and blocks the reuptake of serotonin
What signs/ sx does Ecstasy cause?
- Increased energy
- Euphoria
- Emotional warmth
- Self acceptance
What are side effects of ecstasy?
- Jaw clenching
- Long lasting confusion
- Inability to regulate body temp
- Kidney damage
- Down regulation of serotonin receptors
What effect do salvia and bath salts have?
Both are hallucinogenic effects
