HA/Seizure/MDD/Anxiety Flashcards
characteristics of tension HA
dull with pain that radiates from forehead to occiput in a band-like fashion. Often radiates down the neck and sometimes into the trapezius muscle
characteristics of migraine HA
throbing head pain and often nausea, appetite change, photophobia, phonophobia
characteristics of cluster HA
disabling, burning, or boring and centered around one eye. Unilateral. Refer to neurologist or HA specialist
main inhibitory neurotransmitter in the CNA
GABA
excitatory neurotransmitters in CNA
glutamate
aspartate
2 major groups of seizures
partial
generalized
focal seizures (simple partial)
no alteration of consciousness
symptoms determined by anatomical location of seizure in the brain and may be motor, sensory, autonomic, or psychic
may evolve into complex partial or generalized tonic-clonic
complex partial seizure (psychomotor)
impaired consciousness with some sort of automatic behavior
may be proceeded by an aura
types of generalized seizures
absence atypical absence tonic-clonic clonic atonic myoclonic tonic
absence seizures (petit mal)
sudden onset, brief, disrupt ongoing activity, no postictal state
blank stare and nonresponsive when spoken to
tonic-clonic seizures (grand mal)
abrupt loss of consciousness. bilateral jerking movements, increased salivation, frothing at the mouth, deep respiration and relaxation of muscles. Vague, ill-defined warning sign but no true aura. Postictal period with depressed consciousness that can be prolonged
clonic seizures
rapidly repetitive bilateral jerking movements of extremities and facial muscles with short postictal state
atonic seizures (drop attacks)
sudden loss of muscle tone which may be only fragmentary. May be brief and not associated with loss of consciousness
myoclonic seizures
sudden, brief, shock like muscular contractions
tonic seizures
brief, generalized tonic contractions with associated head extension, possible stiffening of back and stiffening or all 4 extremities
status epilepticus
life threatening emergency. Seizure activity lasting longer than 30 minutes or two sequential seizures with no recovery between
precipitating factors for status epilepticus
drug noncompliance sudden withdrawal from antiepileptic drugs withdrawal from alcohol/sedative drugs CNS infection metabolic disturbances sleep deprivation stroke trauma encephalitis
apparent unprovoked first seizure
EEG, CT or MRI
phenytoin use
one of the most commonly used for tonic-clonic as well as simple and complex partial seizures. Also used to prevent early posttraumatic seizures after TBI
does phenytoin require a loading dose
yes
contraindications to phenytoin
no absolutes
black box warning for severe cardiac events with rapid IV admin
dosage titration of carbamazepine
don’t decrease due to slightly elevated level during 1st month as it will likely decrease as a result of autoinduction. If it is decreased it will likely continue to decrease and dosage should be increased
carbamazepine for myoclonic seizures
not effective and may in fact exacerbate
self-interaction of carbamazepine
can induce its own metabolism resulting in decreased serum concentrations over time (induces and is metabolized by CYP3A4)
what else does oxcarbazepine interact with
oral contraceptives
black box warning for valproic acid
potential for hepatic failure
risk of hepatotoxicity with known mitochondrial disorders
spina bifida (do not give to pregnant patients)
severe life-threatening pancreatitis
symptoms of hepatotoxicity
malaise, weakness, facial edema, anorexia, jaundice, and vomiting
Valproic acid and carbapenems
rapid decline in valproate plasma concentrations
does phenobarbital require a loading dose
yes
black box warning for ezogabine
may cause retinal abnormalities which can loss loss of visual acuity
contraindications to pregabalin
hx of angioedema, HF, HTN, DM
dosage of topiramate in relation to creatinine clearance
<70 dosage should be lowered by 50%
black box warning for felbamate
100-fold increased risk for aplastic anemia (avoid use in patients with history of blood dyscrasias)
black box warning for vigabatrin
may cause permanent bilateral concentric visual field constriction
visual assessment with vigabatrin use
baseline, week 4, then q3mo
rufinamide administration
give with food for increased absorption
dosing of clobazam
based on patient weight
clobazam interactions
alcohol can increase concentration by as much as 50%
can reduce effectiveness of birth control
benzodiaepines for seizure control
clobazam
clonazepam
lorazepam
diazepam
clonazepam contraindications
narrow-angle glaucoma severe liver disease chronic respiratory disease impaired renal function mentally challenged
medications that greatly increase diazepam levels by altering clearance
SSRIs
sertraline
paroxetine
first line treatment for SE
benzodiazepines
most common seizure syndrome in pediatrics
Lennox-Gastaut syndrome ( usually associated with mental retardation)
poor prognosis for seizure control
geriatric considerations for antiepileptic drugs
decreased liver/renal function
lower albumin levels can caus higher free drug concentrations increasing likelihood of adverse reactions
AEDs that can lead to contraceptive failure
topiramate, oxcarbazepine, and lamotrigine
whn AED is started or changed, how many half-lives to reach steady state
5 elimination half-lives
which AEDs limit their own half0life when given chronically
carbamazepine and valproic acid
postpartum depression onset
within 6 weeks of childbirth and can persist for 3-14 months
acute treatment phase of depression
6-8 (potentially up to 12) weeks
full assessment of effectiveness at weeks 4-6
continuation phase of depression tx
usually 9mo-1yr
continue therapy for 4-6 months after symptom resolution
when is maintenance therapy considered for depression
3+ prior episodes 2 episodes in 5 yrs comorbid substance abuse or anxiety disorder family hx onset earlier than 20 or later than 40
adequate trial of antidepressant medication
6-12 weeks
antidepressant drug classes
SSRIs SNRIs TCAs MAOIs atypical agents
administration of SSRIs
take in am d/t potential to induce anxiety and/or insomnia
SSRI drugs
citalopram (Celexa) fluoxetine (Prozac) fluvoxamine (Luvox) paroxetine (Paxil) sertraline (Zoloft) escitalopram (Lexapro)
SNRI drugs
venlafaxine (Effexor)
desvenlefaxine (Pristiq)
duloxetine (Cymbalta)
levomilnacipran (Fetzima)
MAOI drug
phenelzine (Nardil)
Atypical antidepressant drugs
bupropion (Wellbutrin)
mirtazapine (Remeron)
trazadone (Desyrel)
why are SSRIs ideal for elderly
no potential to induce orthostatic hypotension or cardiac conduction abnormailities
use caution with seizure disorders as lowers seizure threshold
symptoms of “discontinuation syndrome” with SSRIs
return and worsening of depressive symptoms with a flu-like presentation, insomnia, irritability, GI effects, and anxiety
most frequently reported SSRI adverse effect
pervasive sexual dysfunction
Wellbutrin has been utilized to mitigate
symptoms of serotonin syndrome
heat stroke
vascular collapse
fever
tachycardia
abrupt discontinuation of SNRIs
also produces discontinuation syndrome
what may be an appropriate option is depression is characterized by insomnia
TCA as they can cause sedation
TCAs that are advantageous for elderly
nortriptyline and desipramine (Norpramin) d/t less potential to cause orthostatic hypotension
contraindications to TCAs
preexisting epilepsy and cardiac conduction abnormalities (may contribute to AV block and QT prolongation)
TCA mech of action
inhibits reuptake of norepinephrine and serotonin
Atypical antidepressant drugs
bupropion
trazadone
nefazodone
mirtazapine
what makes bupropion different from all other available antidepressants
Inhibits reuptake of norepinephrine and dopamine. Does not affect the serotonergic system
benefits of bupropion over other antidepressants
virtual absence of sexual side effects
less somnolence, fatigue, and weight gain
adverse effect of bupropion
lowers seizure threshold
why is trazadone highly sedating
secondary to its antihistamine properties
what else can trazadone be used for
comorbid anxiety disorders
off label sleep aid
SSRI wash out period
4-5 days for zoloft and paxil and several weeks for prozac
mirtazapine appetite stimulation
may make it a good option for low-weight elderly or ill patients
Novel antidepressant drugs
vilazodone
vortioxetine
vilazodone and vortioxetine onset of effect
significantly earlier than other antidepressants (as early as 1 week)
what risks serotonin syndrome when coadministered with vortioxetine
bupropion or buspirone
MAOI orthostatic hypotension
attempts to counteract this include support stockings, prescribing stimulants (methylphenidate), or adding the mineralocorticoid
MAOI diet
strictly eliminate tyramine-containing foods (may cause hypertensive crisis)
first line therapy for MDD
SSRIs or SNRIs unless contraindications
second line therapy for MDD
increase dose, augmentation, or switching
typical agents used to augment antidepressant therapy
lithium
thyroid hormone
stimulant medications
when switching medication classes for MDD what should be chosen prior to TCAs
atypical antidepressants
MDD medications commonly added to initial medication for combo therapy
trazadone bupropion mirtazapine buspirone atypical antipsychotics
why should venlafaxine (effexor) be avoided with uncontrolled HTN
potential to increase BP
depression presentation in children
early childhood: acting out, changes in eating/sleeping, social withdrawal
5-8: low self-esteem, underachievement at school, aggressive or antisocial behavior (including stealing and lying)
MDD medication approved for use in children
Prozac is the only SSRI for children 8+
Lexapro approved for 12+
MDD presentation in elderly patients
more vegetative symptoms and cognitive disturbances than subjective dysphoria
St. John’s wort for MDD
do not take in combo with any other antidepressant d/t risk of serotonin syndrome
can decrease serum levels of warfarin and oral contraceptives
anxiety disorders
generalized anxiety disorder (GAD)
panic disorder (PD)
social anxiety disorder (SAD)
GAD must be present for at least 6 months and have at least 3 of what 6 arousal symptoms
restlessness fatigue muscle tension irritability concentration deficit sleep disturbance
how long should tx of anxiety disorders continue after resolution of symptoms
12 months
SSRIs used to tx anxiety
citalopram (Celexa) escitalopram (Lexapro) fluvoxamine (Luvox) paroxetine (Paxil) sertraline (Zoloft)
TCA used to tx anxiety
Imipramine (Tofranil)
SNRI used to tx anxiety
venlafaxine (Effexor)
duloxetine (Cymbalta)
what else can Cymbalta tx other than anxiety and depression
somatic pain
indication for benzodiazepine tx in anxiety disorders
short term usage (2-4 weeks) while long term therapy takes effects
or on as as-needed basis for panic attacks
high potency BZDs
alprazolam (Xanax)
clonazepam (Klonopin)
lorazepam (Ativan)
preferred drugs for tx of anxiety in the elderly and people with liver disease
oxazepam and lorazepam due to one-step inactivation
highly lipid soluble BZD
diazepam (Valium)
reported possible adverse effects of BZDs in children, elderly, and brain-injury patients
rage
excitement
hostility
drug to tx BZD OD
flumazenil (Mazicon)
Buspirone
primarily used as adjunctive therapy (delayed onset of action, lack of efficacy in relation to most comorbid conditions)
effect may take 2-3 weeks
examples of tyramine-containing foods
cheese, liver, yogurt, yeast, soy sauce, red wine, beer
1st line therapy for GAD
SSRIs/SNRIs with BZD to use until therapeutic effect is realized
2nd line therapy for GAD
imipramine or buspirone (may be the best choice for patients with a hx of substance abuse, personality disorder, or sleep apnea)
3rd line therapy for GAD
TCA alone or buspirone
4th line therapy strategies for GAD
SSRI/SNRI with an AAP
SSRI/SNRI with antihistamine (hydroxyzine)
SSRI with imipramine
SSRI with a BZD
1st line therapy for panic disorder
SSRIs or venlafaxine (Effexor)
Xanax is only BZD approved by the FDA but Klonopin and Ativan are also used
CBT is very important
2nd line therapy for panic disorder
may change to another SSRI or venlafaxine
3rd line therapy for panic disorder
may switch to yet another SSRI, imipramine, or MAOI
1st line therapy for social anxiety disorder
SSRIs or venlafaxine
CBT
2nd line therapy for social anxiety disorder
MAOI phenelzine can be attempted in select patients
BZDs approved for tx of anxiety in children
clorazepate
chlordiazepoxide
diazepam
alprazolam
MDD/anxiety meds associated with fetal heart defects and other teratogenicities
fluoxetine (Prozac)
paroxetine (Paxil)
pregnancy category of antidepressants
most are C
bupropion is B
paroxetine is D
3 components of withdrawal syndrome
relapse: return to symptoms
rebound: worse symptoms than originally experienced
withdrawal: appearance of new symptoms
monitoring patients on long term BZD therapy
periodic CBC, LFT, thyroid function tests
