CNS Part 2 Flashcards
Focal (partial) seizures
Only affect one part of the brain/ typically one cerebellar hemisphere
May progress to affect the whole brain
Generalized seizures
Subclassifications include tonic-clonic (“grand mal”) and absence
Affects the whole brain
Barbiturates role in therapy
Phenobarbital, Primidone
Limited by Side Effects
For resistant seizures as IV therapy
Treats a wide variety of seizure types
Benzodiazepines role in therapy
First line for acute termination of seizures / status epilepticus
Long term use- role limited to specific types of seizures
Alcohol withdrawal seizures
Phenytoin / Fosphenytoin side effects
Confusion, sedation, nystagmus, ataxia, dysarthria
Toxicity Risk- narrow therapeutic index
Phenytoin / Fosphenytoin role in therapy
Acute termination (IV)
Chronic seizure therapy in resistant patients (PO)
Carbamazepine / Oxcarbazepine side effects
Dizziness, drowsiness, ataxia, blurred vision, cardiac arrhythmias
Carbamazepine / Oxcarbazepine role in therapy
Chronic seizure management (PO)
Off-label: trigeminal neuralgia
Valproates side effects
Depakote, valproic acid
GI distress, impaired platelet function
Valproates role in therapy
Acute Seizure management (Inpatient)
Chronic seizure management (PO)(Outpatient)
Other indications: Bipolar disorder, migraines (off-label)
Levetiracetam
Traumatic brain injury seizure, very well tolerated, used for TBI to prevent seizures
Gabapentin (Neurontin)
Neuropathic pain, postherpetic neuralgia, anxiety, restless leg, vasomotor sx in menopause
Pregabalin (Lyrica)
Fibromyalgia, neuropathic pain, diabetic neuropathy, restless leg, chronic cough*
Lamotrigine (Lamictal)
Bipolar, migraine, trigeminal neuralgia
Topiramate (Topamax)
Migraines, tremor, cluster headache
First vs Second Generation AEDs
First: more effective
Second: more favorable kinetics, milder side effects
-Doses administered late can increase risk of seizure occurring
Gabapentin side effects
sedation, fatigue, dizziness
Lacosamide side effects
dizziness, HA, double vision
Lamotrigine side effects
ataxia, skin reactions (SJS)
Levetiracetam side effects
sedation, dizziness, well tolerated
Pregabalin side effects
peripheral edema (temporary)
Tiagabine side effects
rare depression,anxiety
Topiramate side effects
sedation, dizziness, ataxia
Zonisamide side effects
sedation, loss of appetite
AEDs in Pregnancy
Birth defects incidence is generally higher in women who take AEDs compared to those without exposure
Avoid valproic acid and derivatives (can cause spina bifida
Status Epilepticus
Seizure lasting > 5 minutes or
Lack of recovery between seizures
Status Epilepticus management
1st line: BENZOS
2nd therapy: levetiracetam, fosphenytoin, valproic acid, lacosamide
If untreated, can lead to permeant brain damage even death
Gets harder to treat, the longer the seizure lasts
Levodopa
Cornerstone of therapy
Improves bradykinesia and rigidity
Most effective drug therapy
Limited by:
Adverse effects
Diminished response over time
Levodopa-carbidopa (Sinemet)
Erratic absorption & short half life
Absorption delayed if taken with high protein meal
Peak effects: 1 hour after administration
Dosed frequently: >4 times daily
Levodopa ADEs
arrhythmias, OH, Confusion
Dopamine Agonists (Pramipexole, Ropinirole, Rotigotine)
Indications: 1st line alternative agent or in combo with levodopa
Helpful for end-of-dose akinesias & on-off phenomenon
ADE: N/V, orthostatic hypotension
Anticholinergic Drugs: Benztropine (Cogentin), Diphenhydramine (Benadryl)
Indications: tremor; adjunct to levodopa
ADE: confusion, decreased cognition, drowsiness, urinary retention, blurred vision
Avoid in pts 65 or older
Amantadine
Indications: tremor, mild dyskinesias
ADE: orthostatic hypotension, CNS disturbances (hallucinations, depression, confusion), lower extremity skin discoloration
Well tolerated, stimulating (take in early AM and early PM), effects wear off around 1 year
Monoamine Oxidase B inhibitors (Rasagiline, Selegillene)
Indication: Early in disease prior to levodopa or adjunct to levodopa wearing off
ADE: Dizziness, GI distress, HA, sleep disturbances (S>R)
Catechol-O-Methyltransferase (COMT) Inhibitors (Entacapone, tolcapone)
2nd line therapy for ‘wearing off’ of levodopa
Adverse Effects:
Muscle cramps
Dyskinesias (at initiation)
Special Considerations for Physical Therapist
Coordinate therapies with peak drug
effects (levodopa ~1 hr post-dose)
Morning hours may be ideal given late day fatigue
May encounter ‘drug holiday’ patients
Need to maintain as much mobility as possible.
Monitorblood pressure
-Orthostatic hypotension
-Dizziness, confusion, sleep disturbance
Careful guarding given fall risk
Gait training, balance activities are essential to quality of life
Benzonatate
Local anesthetic
Diphenhydramine
Antihistamine
causes sedation, dizziness
Dextromethorphan
Inhibits cough reflux via direct effects on the brainstem
causes sedation, dizziness, GI upset
Codeine / Hydrocodone
Inhibits cough reflux via direct effects on brainstem
causes sedation, dizziness, GI upset, dependence risk
Decongestants
Bind alpha receptors in blood vessels of nasal mucosa =Vasoconstriction
Increased BP
Cardiac abnormalities
Dizziness
Palpitations
first generation Antihistamines side effects
Sedation
Fatigue
Dizziness
GI Distress
Mucolytics
decrease viscosity of respiratory secretions
side effects: Nausea, vomiting, Oral mucosa, inflammation
Expectorants
facilitate production and ejection of mucus
side effects: GI upset
SABA
Short Acting Beta Agonist
Albuterol
Levalbuterol
LABA
Long Acting Beta Agonist
Salmeterol
Formoterol
Vilanterol
Beta-Adrenergic Agonists (Beta Agonist)
Beta Agonists stimulate beta 2 receptors resulting in relaxation of bronchiole smooth muscles producing bronchodilation
Side effects:
Tachycardia
Nervousness
Tremor
Airway irritation (only with excessive use)
Albuterol (SABA)
Acute Symptoms
Onset: 5-15 minutes
Duration of action: 4-6 hours
“Bring with you to PT”
SAMA
Short Acting Muscarinic Antagonist
LAMA
Long Acting Muscarinic Antagonist
Anticholinergic Drugs side effects (Ipratropium, Tiotropium)
Tachycardia
Confusion
Glucocorticoids / Corticosteroids / ‘Steroids’
inhibits inflammatory response
Side Effects – short term
*Oral Thrush (inhalation)
* Hyperglycemia
* Psychiatric disturbances
Side Effects – long term
* Osteoporosis
* Skin breakdown
* Loss of adrenal function
Cromones
Help PREVENT bronchospasm
Taken prophylactically
Prevent release of histamine
Example: Cromolyn
Leukotriene Inhibitors
Leukotriene are inflammatory mediators in resp tissue
Example: Montelukast (Singular) – blocks the receptor for leukotrienes on resp tissue
-Tablet, taken daily
Physical Therapy & Respiratory Drugs
Chest PT scheduling – 30 min/1hr after respiratory med treatments (SABA/SAMAs)
Bring Albuterol to therapy
