Insomnia, Psychoses, Parkinsonism Flashcards
is it appropriate to use sedating side effects of other medications for insomnia?
no- short acting benzos or benzo receptor agonists are drugs of choice. drugs w sedative se include antipsych, antihistamines, antidep, quetiapine, etc
appropriate length of therapy for benzo use in insomnia
2 weeks- avoids developing dependence and withdrawal sx
which benzo may be best in insomnia with concurrent anxiety
clonazepam- long half life so if given at night may promote sleep but manage daytime anx
should you use more than one benzo to manage anx and sleep in one patient
no- inappropriate
4 benzos officially indicated for insomnia- which two are not recommended
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
benefits of temazepam for insomnia
half life covers sleep period without hangover effects, less rebound insomnia vs more potent agents (ex loraz)
why is use of triazolam not particularly recommended in insomnia even though its indicated
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
comment on oxazepam in insomnia
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
how does zopiclone work in insomnia
benzodiazepine receptor agonist. Can have residual hangover effects but tolerance to hypnotic effect may be delayed and rebound insomnia reduced.
zolpidem in insomnia, and its SE
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
which hypnotics can alcohol be combined with
none
melatonin’s role in insomnia
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
preferred hypnotic in pregnancy
zopiclone
what do 2nd gen antipsychotics have greater affinity for vs first
seratonin vs DA
which antipsychs must be given with food and why
lurasidone-2nd gen- minimum 350 cal to max F
ziprasidone-2nd- minimum 500cal to max F
which antipsychotic is not metabolized in liver (potential for fewer DI) and what is this drug related to?
paliperidone, related to risperidone (active metabolite of it)
antipsych with proven efficacy in treatment resistant schizo? what else does it do
clozapine (only one)- reduces suicidality, all cause mortality and hostility and aggression
difference between 1st and 2nd gen antipsych in terms of efficacy
both good for positive sx, 2nd may be better for negative
how should antipsychs be titrated up? which need more rapid? which can be started at recommended dose
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
how to treat acute aggression and anxiety in schizo
benzos
when changing or starting antipsych, how long of a trial shold uyou give?
4-8 weeks- if no benefit seen even minimally, unlikely to ever benefit, consider switch
comment on zuclopenthixol in psychoses/schizo
injectable, 1st gen,peak level 24-48 hours, long acting for acute agitation or aggression, do not use in antipsych naive patients
which antipsych much be titrated quickly and why
ziprasidone; slow associated with poorer outcomes and restlessness, afitation and insomnia (“ziprasidone induced acitvation syndrome)
how to change antipsychs or stop
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.
long acting IM antipsych vs oral
just as effective, promote adherence
name 2 drugs that have their metabolism induced by smoking used for schizo- what are the consequences
olanz and clozapine- need higher doses, so increased SE and AE
side effects of 2nd gen antipsychs: most likely sedation
all can cause! worst cloz >olanz>quet
side effects of 2nd gen antipsychs: most likely insomnia
aripiprazole, paliperidone >risp, zipras > asenapine and lurasidone can be either way,
side effects of 2nd gen antipsychs:most likely EPS
paliperidone > risp >aripip > others
side effects of 2nd gen antipsychs: weight gain/metabolic abnormalities
clozapine, olanzapine >quet>paliperidone>risp
side effects of 2nd gen antipsychs: hyperprolactinemia
paliperidone >risp
side effects of 2nd gen antipsychs: CV effects
cloz/zipras most, all others can but very low
compare triptans
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
who are triptans CI in
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
use tripatans and ergot derivatives for less than __ days per month
10
migraine prophylasxis agents
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
migraine in pregnancy
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
what should be avoided post partum
any vasoconstricting agents, such as triptans or ergots, as there is an increased risk postpatrum for stroke or angiopathy
breastfeeding and migraine
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
side effects of triptans
chest discomfort, fatigue, dizziness, drowsiness, N, paresthesias
SE of all TCAs
drowsy, weight gain, antichol, lower seizure threshold, confusion
quinine for leg cramps
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
antivirals for shingles (herpes zoster)
reduce severity, no evidence that prevent post herpetic neuraligia, most effectie if started within 72 hours of rash onset
carbamazepine for nerve pain
not unless shock like component like in trigeminal neuralgia
agents for neuropathic pain
1st line TCA or gabapentin/pregab, 2nd SNRI (dulox/venla) or topical lidocaine, 3rd tramadol or sustained release opioid
most common agents for drug induced parkinsonism
antipsych, central DA blocking antiemetics (metoclopromaide and prochlorperazine)
what is levodopa always combined with and why
carbidopa or benserazide- increases distribution to brain and minimizes acute SE like N/V
overtime levodopa doesn’t work as well for parkinson’s patients because
disease progression, not drug not working- happens after about 5 years
name DA agonists- what are they used for, which are preferentially used
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
side effects of DA agonists
daytime sleepiness or sleep attacks, impulse disorder (gambling, hypersexual), GI upset, orthostatic hypotension, psych reactions (confusion, hallucinations)
MAOB inhibitors in parkinsons
selegiline (irreversible) no substantial benefit. Rasagiline has more evidence to help with wearing off and maybe slow disease progression
anticholingergics in parkinsons
benztropine, procyclidine- major effect of tremor, little or none on bradykinesia
COMT inhibitors for parkinsons- side effects
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
amantadine in parkinsons
NMDA antagonist, SE= leg edema, erythema, mottled skin appearance of blue color (“livedo riticularis”)
should levodopa be tapered?
yes gradually to prevents parkinsonism hyperpyrexia syndrome
