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OTC > Insomnia, Psychoses, Parkinsonism > Flashcards

Insomnia, Psychoses, Parkinsonism Flashcards

1
Q

is it appropriate to use sedating side effects of other medications for insomnia?

A

no- short acting benzos or benzo receptor agonists are drugs of choice. drugs w sedative se include antipsych, antihistamines, antidep, quetiapine, etc

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2
Q

appropriate length of therapy for benzo use in insomnia

A

2 weeks- avoids developing dependence and withdrawal sx

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3
Q

which benzo may be best in insomnia with concurrent anxiety

A

clonazepam- long half life so if given at night may promote sleep but manage daytime anx

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4
Q

should you use more than one benzo to manage anx and sleep in one patient

A

no- inappropriate

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5
Q

4 benzos officially indicated for insomnia- which two are not recommended

A

flluraz, nitraz, temaz, triaz- first two esp in elderly not recommended bc of long t1/2 and potential to accumulate and more hangover effects. In elderly- higher cortical impairment and confusion/falls

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6
Q

benefits of temazepam for insomnia

A

half life covers sleep period without hangover effects, less rebound insomnia vs more potent agents (ex loraz)

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7
Q

why is use of triazolam not particularly recommended in insomnia even though its indicated

A

fast onset and short DOA- best for first third of night vs last third. Confers higher abuse and dependence potential bc short t1/2. 5-7 days recommended if used. Rebound insomnia, dose related AE liek confusion, agitation, amnesia- not suitable for elderly

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8
Q

comment on oxazepam in insomnia

A

not officially indicated, but is as effective as them. Give 60-90 minutes before bed because of slow absorption (aware sedation/impairment can occur any time on it) If trouble staying asleep more but no problem falling asleep take at bed

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9
Q

how does zopiclone work in insomnia

A

benzodiazepine receptor agonist. Can have residual hangover effects but tolerance to hypnotic effect may be delayed and rebound insomnia reduced.

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10
Q

zolpidem in insomnia, and its SE

A

preferential affinity to benzodiazepine type one receptors. Memory disturbances, complex sleep behaviours like night eating, etc reported. Lower dose in women and elderly because of this usually

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11
Q

which hypnotics can alcohol be combined with

A

none

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12
Q

melatonin’s role in insomnia

A

small decrease in time to onset of sleep and increase in sleep time (both less than 10 minutes) and improved overall sleep quality- may have a role given benign SE profile but evidence mixed

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13
Q

preferred hypnotic in pregnancy

A

zopiclone

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14
Q

what do 2nd gen antipsychotics have greater affinity for vs first

A

seratonin vs DA

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15
Q

which antipsychs must be given with food and why

A

lurasidone-2nd gen- minimum 350 cal to max F

ziprasidone-2nd- minimum 500cal to max F

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16
Q

which antipsychotic is not metabolized in liver (potential for fewer DI) and what is this drug related to?

A

paliperidone, related to risperidone (active metabolite of it)

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17
Q

antipsych with proven efficacy in treatment resistant schizo? what else does it do

A

clozapine (only one)- reduces suicidality, all cause mortality and hostility and aggression

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18
Q

difference between 1st and 2nd gen antipsych in terms of efficacy

A

both good for positive sx, 2nd may be better for negative

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19
Q

how should antipsychs be titrated up? which need more rapid? which can be started at recommended dose

A

titrate to therapeutic dose over 1-2 weeks, ziprasidone and extended release quetiapine need rapid, asenapine and lurasidone can be started at recommended therapeutic dose

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20
Q

how to treat acute aggression and anxiety in schizo

A

benzos

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21
Q

when changing or starting antipsych, how long of a trial shold uyou give?

A

4-8 weeks- if no benefit seen even minimally, unlikely to ever benefit, consider switch

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22
Q

comment on zuclopenthixol in psychoses/schizo

A

injectable, 1st gen,peak level 24-48 hours, long acting for acute agitation or aggression, do not use in antipsych naive patients

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23
Q

which antipsych much be titrated quickly and why

A

ziprasidone; slow associated with poorer outcomes and restlessness, afitation and insomnia (“ziprasidone induced acitvation syndrome)

24
Q

how to change antipsychs or stop

A

crossover period of 2 weeks to 3 months. If stopping taper over 2-4 weeks, or 6-12 months if first episode patients, or 6-24 months if patients experienced 2 or more episodes.

25
Q

long acting IM antipsych vs oral

A

just as effective, promote adherence

26
Q

name 2 drugs that have their metabolism induced by smoking used for schizo- what are the consequences

A

olanz and clozapine- need higher doses, so increased SE and AE

27
Q

side effects of 2nd gen antipsychs: most likely sedation

A

all can cause! worst cloz >olanz>quet

28
Q

side effects of 2nd gen antipsychs: most likely insomnia

A

aripiprazole, paliperidone >risp, zipras > asenapine and lurasidone can be either way,

29
Q

side effects of 2nd gen antipsychs:most likely EPS

A

paliperidone > risp >aripip > others

30
Q

side effects of 2nd gen antipsychs: weight gain/metabolic abnormalities

A

clozapine, olanzapine >quet>paliperidone>risp

31
Q

side effects of 2nd gen antipsychs: hyperprolactinemia

A

paliperidone >risp

32
Q

side effects of 2nd gen antipsychs: CV effects

A

cloz/zipras most, all others can but very low

33
Q

compare triptans

A

all safe and efficacious, may be small clinically meaningful differences between agents for patients so if one doesn’t work try another, riza may provide fastest releif, nara has slow onset with max effect at 4 hours but lower rates of headache re-occurance and about same as placebo for SE profile

34
Q

who are triptans CI in

A

cardiac disorders (ischemic heart disease), sustained HTN, basilar and hemiplegic migraine, with MAOIs, caution with other seratonin agents for seratonin syndrome, if used another triptan in the last 24 hours

35
Q

use tripatans and ergot derivatives for less than __ days per month

A

10

36
Q

migraine prophylasxis agents

A

beta blockers (propran, metop, nadol), TCA, venlafax, valproic acid and divalproex, topiramate, frovatriptan for 5-7 days starting 2 days before menses if that is trigger

37
Q

migraine in pregnancy

A

non pharm and acet best, ibu or naprox if 1st or 2nd tri, ergot derivatives CI (restrict uterine blood flow), triptans avoided but might be safe (suma most evidence), if need proph use propranolol

38
Q

what should be avoided post partum

A

any vasoconstricting agents, such as triptans or ergots, as there is an increased risk postpatrum for stroke or angiopathy

39
Q

breastfeeding and migraine

A

has a positive effect- encourage it, acet preferred agent, ibu too, avoid ergot and opioids, suma studied most of tripatans and looks safe, proph propranolol preferred, valproic and divalproex okay here but NOT in preg

40
Q

side effects of triptans

A

chest discomfort, fatigue, dizziness, drowsiness, N, paresthesias

41
Q

SE of all TCAs

A

drowsy, weight gain, antichol, lower seizure threshold, confusion

42
Q

quinine for leg cramps

A

only for severe where non pharm (regular stretching, good fluid intake, etc) have failed, can have sig AE (cardiac arrhythmias, thrombocytopenia, etc) also headache, dizzy, tinnitus, gait and visual impairment. Withdraw q3m to reassess if still needed

43
Q

antivirals for shingles (herpes zoster)

A

reduce severity, no evidence that prevent post herpetic neuraligia, most effectie if started within 72 hours of rash onset

44
Q

carbamazepine for nerve pain

A

not unless shock like component like in trigeminal neuralgia

45
Q

agents for neuropathic pain

A

1st line TCA or gabapentin/pregab, 2nd SNRI (dulox/venla) or topical lidocaine, 3rd tramadol or sustained release opioid

46
Q

most common agents for drug induced parkinsonism

A

antipsych, central DA blocking antiemetics (metoclopromaide and prochlorperazine)

47
Q

what is levodopa always combined with and why

A

carbidopa or benserazide- increases distribution to brain and minimizes acute SE like N/V

48
Q

overtime levodopa doesn’t work as well for parkinson’s patients because

A

disease progression, not drug not working- happens after about 5 years

49
Q

name DA agonists- what are they used for, which are preferentially used

A

bromocriptine, pramipexole, ropinirole. parkinsons monitherapy in early stages or adjunct with levo/carb later on. Bromo can cause pulmonary fibrosis so other two are preferrably used

50
Q

side effects of DA agonists

A

daytime sleepiness or sleep attacks, impulse disorder (gambling, hypersexual), GI upset, orthostatic hypotension, psych reactions (confusion, hallucinations)

51
Q

MAOB inhibitors in parkinsons

A

selegiline (irreversible) no substantial benefit. Rasagiline has more evidence to help with wearing off and maybe slow disease progression

52
Q

anticholingergics in parkinsons

A

benztropine, procyclidine- major effect of tremor, little or none on bradykinesia

53
Q

COMT inhibitors for parkinsons- side effects

A

entacapone, tolcapone; must be used with levodopa- prevent its peripheral metabolism- reduce levodopa dose up to 30% at initiation. SE- diarrhea, harmless discoloration of urine, dyskinesias, sleep disorder

54
Q

amantadine in parkinsons

A

NMDA antagonist, SE= leg edema, erythema, mottled skin appearance of blue color (“livedo riticularis”)

55
Q

should levodopa be tapered?

A

yes gradually to prevents parkinsonism hyperpyrexia syndrome

OTC (21 decks)

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