knowledge deck Flashcards
what is unique about Sucralfate (Carafate) MOA
Protective barrier
Disadvantages of Sulcrafate?
QID use
GI effects
Decreases drug absorption
When do you take Sucralfate?
Before meals and at bedtime
How do you recognize PPIs by their generic name
-prazole
Are PPIs more or less powerful than H2RAs
More powerful due to irreversible pump shutdown
are PPIs a single drug therapy for Peptic ulcers?
First line treatment but but not single drug therapy for ulcers plus H.Pylori
PPI used for bleeding or NSAID ulcers; Antacids and H2RB are not
How well tolerated are PPIS
very well tolerated
Potential disadvantages to chronic PPI therapy?
increased risk for food poisoning, HAI (esp c-diff), pneumonia,
How to take PPIs in relation to meals
take before meals to keep the acid production from coming
For H2 receptor antagonists…
use with caution with ______ or _____ disease
kidney or liver
which H2RA has the most drug interactions and why
most drug interactions are from cimetidine (Tagamet) due to CP450 effects
which drug interactions are a problem and why (H2RA)
ETOH and CNS depressants for safety reasons
what population group is at risk for CNS adverse effects for H2RA
elderly
what are the protective factors of the stomach
mucous
bicarb
prostaglandin
The stomach also secretes intrinsic factor which helps with?
B12 absorption
A deficiency in B12 absorption leads to
macrocytic anemia
causative bacteria for peptic ulcer disease
H.Pylori
Treatment for H.Pylori
PPI plus a combo of 2 antibiotics for 1-2 weeks then continue with PPI for 4-8 weeks for healing to occur
Which acid controlling drug neutralizes acid
antacids
What is an example of an antacid
Calcium Carbonate
which acid controlling drug blocks stimulation of production
H2 receptor antagonist
What is an example of a H2 receptor antagonist
Ranitidine
Which acid controlling drug stops the production of acid
Proton pump inhibitors
What is an example of a PPI
Omeprazole
what does sucralfate (Carafate) do
Protects the lining of the stomach
What does simethicone (Mylicon) do?
breaks up gas
who gets stress ulcers and why
after major trauma
due to endogenous and exogenous steroids production (anti-prostaglandins)
what classes of drugs are used to prevent stress ulcers
H2RBs and PPIs
mucous protects against
autodigestion
bicarbonate
helps buffer HCL
prostaglandins
prevent activation of proton pump and increase blood flow, bicarb and mucous production
which antacid has the worst rebound reaction
Calcium carbonate
indications for antacids
Hyperacidity GERD Gastritis Ulcer prevention Calcium and magnesium replacement
How does the pt prevent drug interactions when using antacids
Take 2 hours before or after other meds
cautions for pts using chronic or excessive use of antacids
avoid unsupervised use for greater than 2 weeks, may need a workup
which antacids are more risky if you have diarrhea or renal disease
magnesium
which antacids are more risky if you have constipation
calcium
which antacids are more risky if you have heart failure
sodium
What are the types of laxatives?
Bulk forming Emollient Hyperosmotic Saline Stimulant
Bulk forming MOA
High fiber
Prebiotic effect
absorb water to increase bulk
distends bowel to initiate reflex bowel activity
Metamucil and citrucel are examples of what type of laxative
Bulk forming
foods high in fiber
stems seeds skins of plants whole grains prunes
Emollient MOA
stool softeners and lubricants
promote more water and fat in stools
lubricate the fecal material and intestinal wall
colace and surfak are examples of what type of laxitive
emollient
Examples of lubricants
mineral oil - not absorbed
olive oil - nutritional value (folk remedy)
Hyperosmotics MOA
increase fecal water content
result in bowel distension, increase peristalsis and evacuation
examples of hyperosmotics
Miralax
glycerin (very mild)
Lactulose
what is lactulose also use for
to bring down serum ammonia levels
saline laxative MOA
increases osmotic pressure drawing more water into the intestines
results in bowel distension, increase peristalsis and evacuation
examples of saline laxatives
milk of magnesia
mag citrate
stimulant laxative MOA
Increase peristalsis via intestinal nerve stimulation which is effective higher in the colon
examples of stimulant laxatives
Senna (Senekot)
bisacodyl (Dulcolax)
adverse effects bulk forming laxatives
impaction if the pt is not taking in adequate water
esophageal blockage - need to drink it right away or it starts to thicken
adverse effects of emollient laxatives
skin rashes
decreased absorption of lipid soluble vitamins
risk of aspiration pneumonia esp in a bed ridden pt
adverse effects of hyperosmotic laxatives
abd bloating
cramping
rectal irritation
saline laxative adverse effect
increased thirst, cramping, diarrhea
electrolyte imbalance
for renal insufficiency patients - mag toxicity
stimulant laxative adverse effects
nutrient malabsorption skin rashes gastric, rectal irritation discolored urine dependency
pt education on laxatives
do not use if suspect appendicitis - can lead to rupture
-n/v and severe abd pain
laxative dependency
from an atonic colon, depends on the laxative
laxative abuse
Chronic exposure to laxatives can diminish defecatory reflexes leading to further reliance on laxatives. Laxatives can purge the bowel. Reflex wont return until bowel refills but often time someone thinks they are constipated again because they aren’t having a bm daily. Can lead to electrolyte imbalance, dehydration and colitis
which of the laxatives is best suited for children
glycerin suppository
which of the laxatives is best suited for elderly
stool softeners
Bulk
which of the laxatives is best suited for long term, chronic use
stool softeners
bulk
which of the laxative classes is slowest on onset
stool softeners
Bulk
which of the laxatives is fastest to onset
osmotics
saline
which of the laxative classes is most likely to cause fluid/electrolyte imbalances
saline
which laxative is also used as an antacid
Milk of Magnesia
which laxative is most likely to cause aspiration pneumonia or deficiency of lipid soluble vitamins with prolonged use
Mineral oil
esophageal/Intestinal blockage, which laxatives put you most at risk/ what group is at highest risk
bulk forming
Those with eating disorders are most at risk
duration of acute diarrhea
up to 2 weeks
duration of chronic diarrhea
greater than 3 weeks
other symptoms of chronic diarrhea
recurring diarrheal stools fever poor appetite n/v weight loss weakness
causes of acute diarrhea
bacterial viral drug induced food related protozoa
causes of chronic diarrhea
tumors diabetes mellitus Addisons disease Hyperthyroidism IBS AIDS
example of probiotics
L.acidophilus ( Lactinex)
does probiotics treat or prevent diarrhea
both
example of probiotics
L.acidophilus ( Lactinex)
Yogurt
examples of adsorbents
Pepto-bismol
danger of giving Pepto bismol to children or teenagers with virus
Risk of Reye’s syndrome
examples of adsorbents
Pepto-bismol (Bismuth subsalicylates)
Examples of opiates
Immodium -AD Lomotil paregoric opium tincture codeine
Examples of opiates
Imodium -AD Lomotil paregoric opium tincture codeine
anticholinergics moa
antimotility
slows the movement of fecal matter through GI tract
examples of anticholinergics
atropine - which is in Lomotil
cholinergic effects
Acronym "SLUDGE" Salivation Lacrimation urination Diarrhea GI distress Emesis
anticholinergic toxicity
Blind as a bat mad as a hatter dry as a bone Hot as a dessert red as a beet
Adverse Effects
Adsorbents- Salicylates:
Increased bleeding time
• Decrease absorption of many other drugs
• Constipation, dark stools/ tongue
• Confusion, twitching
• Hearing loss, tinnitus, metallic taste, blue
gums
Adverse Effects
Opiates
- Drowsiness, sedation, dizziness, lethargy
- Nausea, vomiting, anorexia, constipation
- Respiratory depression
- Hypotension
- Urinary retention
- Flushing
Adverse Effects
Anticholinergics
• Urinary retention (esp who?), hesitancy, impotence • CNS effects: Headache, dizziness, confusion, anxiety, drowsiness • Dry skin, flushing • Blurred vision (why?) • Hypotension, bradycardia
Anticholinergic Agents MOA
Blockade of muscarinic receptors in the
striatum
example of an anticholinergic agent
atropine
side effect of anticholinergic agents
Urinary retention, hesitancy, acute glaucoma,
orthostatic BP, decreased sweating
adverse effect anticholinergic agent
Dysrhythmias, risk hyperthermia (esp for ____),
____ glaucoma» _____crisis
adverse effect anticholinergic agent
Dysrhythmias, risk hyperthermia (esp for elderly),
narrow angle glaucoma» angle closure crisis
Anti-diarrheals:
Monitoring/ Pt Education
Teach patients about fluid intake and
dietary changes
• Use salicylates carefully in elderly or those
with bleeding/ clotting disorders, confusion
• Assess hydration/ fluid volume status
• Needs evaluation if bloody stools, with
fever, severe pain, risk dehydration,
prolonged
On what basis is diarrhea defined?
Loose or watery, usually
frequent stools
Which is used in MILD diarrhea?
Adsorbents or probiotics
Why does Lomotil contain atropine?
To
prevent abuse
anti-diarrheal CI (contraindicated) in children?
Bismuth
subsalicylates to prevent Reyes syndrome
Lomotil (and all anti-peristaltics) is CI in what
kind of diarrhea and why?
AAPMC/ C diff as
antibiotics are needed and antimotilty agents
allow more (fatal) toxins to be absorbed
example of an Anticholinergic drugs (ACh blockers)
Scopolamine
• Also used for motion sickness (transdermal patch)
Antihistamine drugs (H1 receptor blockers) examples
dimenhydrinate (Dramamine),
diphenhydramine (Benadryl), meclizine
(Antivert)- specifically for vertigo
Antidopaminergic drugs- phenothiazides examples
prochlorperazine (Compazine), promethazine
Phenergan
Antidopaminergic/ Prokinetic drugs
if the problem is the food is sitting too long and not moving forward so causes the vomiting
Antidopaminergic/ Prokinetic drugs examples
metoclopramide (Reglan)
• Long-term use may cause irreversible tardive dyskinesia»_space;
“Litogenic” - law suit generating
Serotonin blockers examples
ondansetron (Zofran), dolasetron (Anzemet)
NK (neurokinin)1 Receptor antagonist - the only one
• Only one ex: aprepitant (Emend) - expensive
phosphorated carbohydrate solution (Emetrol) MOA
decrease peristalsis and delay gastric emptying • No drug interactions, no serious reactions • Avoid with diabetes great for pregnancy
Taking antiemetics with _______ may cause
severe CNS depression
alcohol
Teach patients to ______ to avoid
hypotensive effects
rise and change positions
diet teaching for n/v
bland diet
wet/dry diet
what is a wet dry diet
eat meal dry with no drink, wait and hour to drink
antiemetics : Many of these drugs cause severe drowsiness;
warn patients ________
about driving/operating heavy machinery
Anticholinergics block
cholinergic receptors ie) Scopolamine
Antihistamines block
Block H1 receptors ie) meclizine
Antidopaminergic block
Block dopamine receptors,
promethazine
Prokinetics block
- Block dopamine receptors and stimulate
stomach emptying ie) metaclopramide
• Serotinin blockers block
- Block 5-HT3 receptors- odansetron
antiemetics Most likely to cause drowsiness?
Anticholinergics,
Antihistamines & Antidopaminergic
antiemetics Most likely to cause dry mouth, blurred vision and
urinary retention?
Anticholinergics, Antihistamines &
Antidopaminergic
Which of the antiemetics is most likely to
cause Parkinsonian SE and tardive dyskinesia
with long term use
Metoclopramide
Which of the antiemetics is indicated for
motion sickness AND vertigo?
Meclizine (Antivert)
Indicated for nausea/ vomiting secondary to
chemotherapy?
Serotonin blockers or NK1
blockers
What pt population(s) are most likely to have
paradoxical reactions from antihistamines?
Kids and elderly
What are alternative modes of administration
besides orally?
Suppositories, IV or patch (scopolamine)
How does you monitor the therapeutic effect
of antinausea/ antiemetic drugs?
Hydration,
weight, urine ketones, tolerance of triggers,
intake/retention of fluids, food
definition of drug abuse
using a drug in a fashion inconsistent with medical or social norms
a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems
substance use disorder
results from regular drug use and can be defined as a state in which a particular dose elicits a smaller response than it did with initial use.
tolerance
a state in which tolerance to one drug confers tolerance to another. (generally in the same class)
cross-tolerance - example is heroin and morphine
an intense subjective need for a particular psychoactive drug
psychological dependence
a state in which an abstinence syndrome will occur if drug use is discontinued. if drug is stopped there is a visible physical symptom
physical dependence
the ability of one drug to support physical dependence on another drug
cross-dependence
ie) a alcoholic who needs ativan to go to work without alcohol
a constellation of signs and symptoms that occurs in physically dependent individuals when they discontinue drug use
withdrawal syndrome
being physically dependent on a drug is/is not the same as having a substance use disorder
is not
ie) someone who has seizures needs to be on a medication to stay seizure free. This is not SUD
explain reinforcement in drugs
a drug can give the individual an experience that is pleasurable
lets say you have someone who is anxious so they take barbituates. This makes them feel better
factors that contribute to substance use disorder
reinforcement of drugs physical dependence psychological dependence social factors drug availability vulnerability of the individual
repeated use of a drug contributes to the transition from voluntary use to compulsive use by causing
molecular changes in the brain
The Comprehensive Drug Abuse Prevention and Control Act of 1970, known informally as the Controlled Substances Act (CSA) objective is to
reduce the chances that drugs originating from legitimate sources will be diverted to abusers
You can only prescribe controlled substances if you have
a DEA licence
what schedule class carry the highest risk for abuse
Schedule II
oral prescriptions for schedule II meds can be called in for an emergency but you must have a written prescription within ____ hours
72
what is the most common used and abused psychoactive agent in the US
alcohol
2 of the biggest negative effects of alcohol
depression of the CNS
activation of the reward system - perpetuates the abuse of this substance
if alcohol is chronically used in excess
injury to CNS
significant nutritional deficiencies
cardiac depressant
alcohol and sleep
commonly used as a sleep aid but it actually
disrupts sleep. alters sleep cycles, decrease total sleeping time, reduces the quality of sleep
can intensify snoring and exacerbate sleep apnea
alcohol and cardiac
dilation of cutaneous blood vessels - increased blood flow to skin (flushing, warm sensation)
direct damage to myocardium - increases risk for heart failure (alcohol induced cardiac myopathy)
dose dependent elevation of BP - deeper tissues you see vasoconstriction
moderate alcohol use
2 drinks a day or less for men
one drink a day or less for women
3-4 days per week
protection is greater than someone who drinks 1-2 days per week
heart benefits of moderate alcohol use
less ischemic stroke less CAD less MI less heart failure as opposed to abstainers raises HDL cholesterol which protects against CAD
the degree of protection with type of alcohol
nearly equal for beer, wine, and distilled spirits
Cardioprotection in regard to drinking is greatest for those
with an unhealthy lifestyle -
for those who exercise, eat fruits and vegetables and do not smoke - alcohol has little or no effect on the incidence of coronary events
conversely - for those who lack these behaviors, moderate alcohol intake is associated with a 50% reduction in coronary risk
alcohol and diabetics
has several effects on glucose metabolism that may decrease the risk for type 2 diabetes.
alcohol and bone health
increases bone mineral density, by increasing levels of sex hormones
alcohol and liver
can sustain large amounts of alcohol use
for chronic drinkers - nonviral hepatitis develops in approximately 90% of heavy users which can evolve into cirrhosis
alcohol abuse is unquestionably the major cause of fatal cirrhosis
alcohol and stomach
excessive use can cause erosive gastritis
alcohol and kidney
alcohol is a diuretic. it can eventually cause renal damage
alcohol and pancrease
can cause pancreatitis (2nd most common cause of this)
alcohol and cancer
alcohol (even in moderate amounts) is associated with increased risk for several common cancers - breast, liver, rectum, aerodigestive tract (lips, tongue, mouth, nose, throat, vocal cords, portions of the esophagus and trachea)
Fetal alcohol spectrum disorder
craniofacial malformations
growth restrictions
neurodevelopmental abnormalities
the concentration of alcohol in breastmilk parallels ____
the concentration of alcohol in blood. Recent data indicates that drinking while breastfeeding can adversely affect the infants feeding and behavior
alcohol is primarily absorbed through
the stomach and small intestines
alcohol is metabolized by
liver and stomach
primarily in the liver
male and female metabolism of alcohol
females have lower activity of alcohol dehydrogenase so gastric metabolism is significantly less in women who metabolize alcohol slower than men
cross tolerance with alcohol
general anesthetics
barbiturates
other general CNS depressants
very little tolerance develops to
resp depression
alcoholics may tolerate blood alcohol levels as high as 0.4% (five times the amount defined by law as intoxicating) with no marked reduction in consciousness. However if blood levels rise only slightly above this level, death may ensue.
drug interactions for alcohol
CNS depression
benzodiazepines
opioids
barbituates
NSAIDS - increase chance of GI bleeding
Acetaminophen - potentially fatal liver injury when taking normal dosing with large amounts of alcohol
Antihypertensive drugs
tends to counteract the effects of antihypertensive medications
monitor BP closely
alcohol poisoning treatment
alcohol lavage
drugs to facilitate alcohol withdrawal
Benzodiazepines in inpatient or outpatient settings
What does benzodiazepines do in alcohol withdrawal
stabilize vital signs
reduce symptom intensity
decrease risk for seizures and delirium tremens
Benzodiazepines used in alcohol withdrawal
chlordiazepoxide
clorazepate (Tranxene)
Oxazepam
Lorazepam (Ativan)
adjunct therapy with benzodiazepines for alcohol withdrawal
B blockers
drugs used to maintain alcohol abstinence
Naltrexone (Vivitrol) - reduces craving for alcohol
blocks the pleasurable effect of alcohol
decreases their high
Acamprosate - not used as much
reduces unpleasant feelings - anxiety, tremors
should be used with counseling
Disulfiram (antabuse) - violent physical reaction
must be careful - risk of death from the physical reaction
types of anxiety disorders
Generalized anxiety disorder (GAD) Panic Disorder (PD) Obsessive Compulsive Disorder (OCD) Social Anxiety Disorder (SAD) Posttraumatic Stress Disorder (PTSD)
for most patients a combination of drug therapy and psychotherapy is
more effective together than either alone
2 drugs used most for anxiety
SSRIs
SNRIs
med used for anxiety with long onset of action
Buspar
first line choices for anxiety disorders
SRIs
SSRIS
SNRIs
Buspar
2nd line for anxiety disorders
Benzos
only 4 antidepressants approved for GAD
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Paroxetine (Paxil)
Escitalopram (Lexapro)
compared with Benzodiazepines the antidepressants do a better job of decreasing cognitive and psychiatric symptoms of anxiety but they are not as good at decreasing
somatic symptoms
so antidepressants do not carry risk for abuse like benzos do
What was the first antidepressant approved for GAD
Venlafaxine (Effexor)
NEVER combine Venlafaxine (Effexor) with a
MAOI inhibitor (rule is to never combine an antidepressant with one)
Buspar is a
anxiolytic - no abuse potential - takes a month to see results. they will need something else while they are waiting for this drug to take effect
Buspar adverse effects
dizziness, nausea, headache, nervousness, sedation, lightheadedness
Drug and food interactions for Buspar
levels greatly increased by erythromycin and ketoconazole and grapefruit juice
panic disorder typically respond to
all 4 classes of antidepressants
what is first line for panic disorders
SSRIS
only 3 SSRIs are approved for panic disorders
fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
first line drugs for OCD
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Sertraline (Zoloft)
Paroxetine (Paxil)
____ therapy is most important in OCD than any other disorder
Behavioral
what TCA is used to treat OCD
Clomipramine (Anafranil)
social anxiety disorder - 2 drugs approved
Paroxetine (Paxil)
Sertraline (Zoloft)
Beta blocker beneficial for social anxiety disorder
Propranolol - musicians and actors use this frequently - also good for test anxiety
off label use
when you prescribe a drug off label, what must you do
inform the patient that it its not approved for this use
PTSD should be treated with ____ in addition to drugs
psychotherapy
drugs for PTSD
beneficial fluoxetine (Prozac) paroxetine (Paxil) - approved Sertraline (Zoloft) - approved Venlafaxine (Effexor)
Sertraline (Zoloft) is used very commonly and more problematic for
GI side effects - so if they have IBS, zoloft wont be your DOG
how long do patients have to have signs of depression before it can be considered major depression?
2 weeks
SSRI MOA is to
increase serotonin available at the presnyeptic cleft
SSRI effects
HEAD
decrease anxiety, decrease impulsivity, decrease sex drive
RED
interfere with plt and bleeding
FED
GI motility
Nausea
What is the number one reason people want to stop taking SSRI
decrease sex drive
How long do SSRI take to work?
4 to 6 weeks
Fluoxetine (Prozac)
SSRI
longest 1/2 life
-1 week
“flu” worst week of your life
if you switch too fast to another SSRI/ MAOIs you can cause Serotonin syndrome
Sertraline (Zoloft)
SSRI
Harsher GI side effects….”Squirt-aline”
take with meal to decrease GI SE
safer for BFing and pregnant women
Paroxetine (Paxil)
SSRI
rapidly absorbed worst SE
inital SE, before clinical improvement
Withdrawal will happen much faster if stopped abruptly
NOT safe during pregnancy d/t withdrawal syndrome
Citalopram (Celexa)
SSRI
effect on QT interval if given >40mg/day >20mg/day in elderly get yearly EKG
Escitalopram (Lexapro)
Cleanest SSRI
Fluvoxamine (Luvox)
SSRI
only approved for OCD
Venlafaxine (Effexor)
SNRI
may be better for patients with lack of energy, decreased concentration
Can cause HTN, don’t use with someone with hx of HTN
Duloxetine (Cymbalta)
SNRI
also helps with chronic pain “dull” for dulls the pain
Mirtazapine (Remeron)
a-2 adrenergic receptor antagonist
- nursing homes cancner clinics
- because it helps increase appetite
- may decrease nausea
Mirtazapine (Remeron)
a-2 adrenergic receptor antagonist
- nursing homes cancner clinics
- because it helps increase appetite
- may decrease nausea
Tricyclic Antidepressants MOA
inhibit the reuptake of SE and NE
antagonizing Ach and histamine
inhibiting Na and calcium channels
TCA overdose can cause
severe cardiac issues
widen QRS complex
what TCA do you give if patient has insomnia
Doxapin
What TCA do you give if you don’t want more sedation
desipramine
If someone has ACH issues (glaucoma, constipation, BPH) what TCA do you give them?
Give notriptyline due to weak ACH effects
Imipramine (Tofranil)
TCA
sometimes used for bed wettting in children
Clomipraimine (anafranil)
TCA
gold standard for OCD but d/t high SE use SSRI first line
use of benzodiazepines in pregnancy and lactation
use during first trimester is associated with increased risk for congenital malformations
use near term can cause CNS depression in the neonate
contraindicated
drug given to promote sleep
hypnotics
what are the 4 major groups of sedative-hypnotics
Barbiturates
Benzodiazepines
Benzodiazepine-like
new agents with unique MOA
When treating anxiety and insomnia which is more preferred out of Barbiturates and Benzodiazepines?
Benzodiazepines
When taken ____, Benzodiazepines have no affect on the heart, but when given ____ can produce profound hypotension and cardiac arrest
PO
IV
What is the drug of choice for acute anxiety
Benzodiazepines
anterograde amnesia
benzodiazepines can cause anterograde amnesia (impaired recall of events that take place after dosing).
anterograde amnesia is especially bad with what drug
triazolam (Halcion)
benzodiazepines and sleep related
taking benzodiazepines in sleep inducing doses may carry out complex behaviors and then have no memory of their actions. include sleep driving, preparing and eating meals, phone calls, ect
benzodiazepines and breastfeeding
can pass through milk easily and can reach toxic levels in the infant. do not use
are drugs for insomnia meant for long term or short term use
short term
Zolpidem (Ambien) is approved only for
short term management of insomnia
Ambien vs Ambien CR
Ambien is good for those who have difficulty falling asleep
Ambien CR is good for those who have difficulty staying asleep
rebound insomnia
When a pt is on long term insomnia therapy when they discontinue the med they are more likely to have rebound insomnia enforcing the behavior that they feel like they need the medication
Zaleplon (Sonata) is approved only for the short-term management of
insomnia
Zaleplon (Sonata) is good for what sleep problem
falling asleep but not staying asleep
Common side effects of Zaleplon (Sonata)
headache nausea drowsiness dizziness myalgia abd pain rare cases of sleep driving
Eszopiclone (Lunesta) is approved for
treating insomnia with no limitation on how it can be used
however there are no studies on use for greater than 6 mos
Eszopiclone (Lunesta) reduced sleep ____
latency and nighttime awakening, increased total sleep time and sleep quality
other common side effects are
headache somnolence dizziness dry mouth sleep driving anaphylaxis or angioedema
Ramelteon (Rozerem) moa
melatonin agonist
approved for insomnia characterized by difficulty with sleep onset but not with staying asleep
what is the only drug for insomnia that is not regulated as a controlled substance
Ramelteon (Rozerem)
did the FDA put a limit on how long Ramelteon (Rozerem) can be used?
no because there was no rebound insomnia
side effects of Ramelteon (Rozerem)
SOMNOLENCE dizziness fatigue may also cause sleep driving hallucinations agitation mania
can increase the levels of prolactin causing amenorrhea galactorrhea reduced libido fertility problems
anyphylaxis
angioedema
drug interactions for Ramelteon (Rozerem)
Fluvoxamine (Luvox) can increase levels more than 50 fold
alcohol can intensify symptoms
what drug may be given during abstinence syndrome to facilitate the withdrawal process
phenobarbital - a long acting barbiturate - dosage should be reduced gradually over 10 days to 3 weeks
Ramelteon (Rozerem) and pregnancy
avoid
Suvorexant (Belsomra)
orexin antagonist
treats insomnia for going to sleep and maintaining sleep
does Suvorexant (Belsomra) have abuse potential
yes
drug interactions for Suvorexant (Belsomra)
Use with strong inhibitors of CYP3A can increase the effects
Can also increase digoxin levels requiring close monitoring
Pregnancy and lactation for Suvorexant (Belsomra)
studies are lacking
Prolonged use of Barbiturates results in ____ ____, a state in which continued use is required to avoid an ____ _____.
physical dependence
abstinence syndrome
symptoms of withdrawal from general CNS depressants
abstinence syndrome
weakness confusion restlessness insomnia hyperthermia orthostatic hypotension disorientation by 3rd day seizures may develop then psychotic delirium (similar to alcoholic delirium tremens) in extreme cases followed by exhaustion cardiovascular collapse and death
progresses over 8 days
what drug may be given during abstinence syndrome to facilitate the withdrawal process
phenobarbital - a long acting barbituate - dosage should be reduced gradually over 10 days to 3 weeks
overdose of barbiturates
apnea and death
what is a heavily abused barbiturate
Xanax
to minimize drug-dependency insomnia, hypnotics should be employed judiciously. That is, they should be
used in the lowest effective dosage for the shortest time required.
Trazodone (oleptro) can decrease
sleep latency and prolong sleep duration
major adverse affect of Trazodone
Can cause Priapism, a medical emergency
Doxepin is an
TCA with strong sedative and also is really good for appetite. used for sleep maintenance in low doses
Doxepin is contraindicated in
pts with severe narrow angle glaucoma and severe urinary retention
another TCA that will help with sleep
Elavil
antihistamines used for sleep aid
Diphenhydramine (Nytol, sominex)
passage across the blood brain barrier is limited to
lipid soluble agents ant to drugs that cross by way of specific transport systems. Protein-bound drugs and highly ionized drugs cannot cross
Can you use a drug that treats muscle spasms to relieve spasticity?
no, these groups are not interchangeable
As a rule, the drugs used to treat spasticity do not relieve acute muscle spasm and the drugs used to treat acute muscle spasm do not relieve spasticity.
A group of movement disorders of CNS origin. characterized by heightened muscle tone, spasm and loss of dexterity.
Spasticity
Spasticity is most commonly caused by
sclerosis
cerebral palsy
other causes - traumatic spinal cord injury
stroke
what are the 4 drugs used to treat spasticity
Baclofen
Diazepam
Tizanidine
Dantrolene
Which is the drug approved for spasticity that instead of working on the CNS, it works on the skeletal muscle
Dantrolene
What is the drug that is approved to relieve spasticity r/t MS and some spinal cord injuries but not approved for spasticity r/t Cerebral Palsy, stroke, Parkinson disease or Huntington chorea
Baclofen
Does Baclofen decrease muscle strength?
no
Because baclofen has no direct muscle relaxant action, it does not decrease muscle strength. For this reason Baclofen is preferred over Dantrolene
Baclofen and CNS
drowsiness dizziness weakness fatigue most intense during early phase of therapy and diminishes with continued drug use
avoid alcohol
Antidote for Baclofen overdose
There is none.
can produce coma and resp depression
supportive therapy should be started immediately
symptoms of abrupt withdrawal of oral Baclofen
visual hallucinations
paranoid ideation
seizures
adverse effects of Baclofen
n/v
constipation
urinary retention
hypotension
Pt education for Baclofen
- possible depressant effects such as drowsiness, lightheadedness, and fatigue
- Avoid driving and operating heavy machinery
- Avoid other CNS depressants
- Frequently causes hypotension, nausea, constipation, urinary retention
- Abrupt discontinuation can cause psychiatric symptoms such as hallucinations, paranoia and seizures
What is the only benzodiazepine labeled for treating spasticity
Diazepam (Diastat, Valium)
Patient education for Dantrolene
- possible depressant effects such as drowsiness, lightheadedness, and fatigue
- Avoid driving and operating heavy machinery
- signs of liver dysfunction are jaundice, abd pain, malaise
- Avoid CNS depressants
Dantrolene can relieve spasticity associated with
multiple sclerosis
cerebral palsy
spinal cord injury
What drug that is approved to relieve spasticity may be associated with a significant reduction in strength
Dantrolene
What should you do if you do not see benefit from Dantrolene within 45 days
discontinue the drug
Black Box Warning for Dantrolene
fatal hepatotoxicity has occurred . The lowest effective dose should be used. Because patients may be asymptomatic, baseline liver function tests should be obtained followed by frequent monitoring of these levels throughout therapy.
involuntary contraction of a muscle or muscle group
muscle spasm
what causes muscle spasm
epilepsy
hypocalcemia
acute and chronic pain syndromes
localized muscle injury
treatment of acute muscle spasm involves
physical measures
drug therapy
What are some examples of adjunct therapy for muscle spasms
physical therapy
specific exercises
whirlpool baths
heat application
application of a cold compress following a musculoskeletal injury
used initially to relieve pain and reduce swelling not to relieve muscle spasm
drug therapy for localized muscle spasms
analgesics (acetaminophen or NSAIDS)
Centrally acting muscle relaxants
What are the centrally acting muscle relaxants used to relieve muscle spasm
carisoprodol chlorzoxazone cyclobenzaprine diazepam metaxalone methocarbamol orphenadrine
what is the drug of choice for acute muscle spasm
Cyclobenzaprine
CNS adverse effects of Cyclobenzaprine
It is a CNS depressant so
drowsiness
dizziness
fatigue
anticholinergic effects of Cyclobenzaprine
dry mouth blurred vision photophobia urinary retention constipation
Cardiac effects of Cyclobenzaprine
cardiac rhythm disturbances- sinus tachycardia and significant conduction delays
Cyclobenzaprine is contraindicated for patients taking
Monoamine Oxidase (MAO) Inhibitors (-ine) make sure there as been at least a 2 week dry out period before starting
SSRI
SNRI
Tricyclic antidepressants
Taking Cyclobenzaprine with an MAO Inhibitor could lead to
potentially fatal serotonin syndrome
- high fevers
- Seizures
- rhabdomyolysis
Tizanidine is indicated for _____ and has been used off label to treat _____
spasticity
acute back pain
What drug is approved for treatment of both spasticity and muscle spasm
Diazepam
what two centrally acting muscle relaxants can cause liver damage and liver function should be assessed before starting treatment
Tizanidine (Zanaflex)
Metaxalone (Skelaxin)
what centrally acting skeletal muscle relaxant can cause hepatitis and potentially fatal hepatic necrosis
Chlorzoxazone (Lorzone)
what centrally acting skeletal muscle relaxant may turn urine brown, black, dark green (harmless)
Methocarbamol
What centrally acting skeletal muscle relaxant may turn urine orange to purple-red (harmless)
Chlorzoxazone
What centrally acting skeletal muscle relaxant can cause dry mouth, hypotension, hallucinations and psychotic symptoms
Tizanidine
What needs to happen when discontinuing Tizanidine and why
The dose needs to be tapered to avoid rebound hypertension
Which antidepressants can be taken safely while breastfeeding?
Sertraline
what are the 2 indications for CNS stimulants
ADHD
narcolepsy
what are the three most widely used CNS stimulants
amphetamines
methylphenidate (Ritalin)
methylxanthines (caffeine)
what drugs are in the amphetamine family
-amphetamine
lisdexamfetamine (Vyvance)
amphetamine
dextroamphetamine
methamphetamine
amphetamines and CNS
prominent affects on mood and arousal increase wakefulness and alertness reduce fatigue elevate mood augment self confidence and initiative
Amphetamines and cardiac
increase HR, atrioventricular conduction, force of contraction
can cause dysrhythmias
can cause HTN
Do amphetamines have a high or low potential for abuse? withdrawal syndrome
chronic use will produce physical dependence
if abruptly stopped withdrawal syndrome will ensue
adverse effects of amphetamines
insomnia
restlessness
weight loss
antiseizure for pregnancy
Lamictal
a disorder characterized by daytime somnolence and uncontrollable attacks of sleep
Narcolepsy
Caffeine and other methylxanthines with neonatal apnea
used to reduce the number and duration of apnea episodes and can promote a more regular pattern of breathing
Modafinil (Provigil) - what is it, what is it used for
non-amphetamine stimulant
approved for wakefulness in patients with narcolepsy, shift-work sleep disorder (SWSD) and obstructive sleep apnea-hypopnea syndrome (OSAHS)
can you use Modafinil during pregnancy
no
what to look for in Modafinil (adverse reactions)
headache nausea nervousness Steven Johnson syndrome erythema multiforme toxic epidermal necrolysis
report - swelling, rash esp with fever
or changes in oral mucosa
does Modafinil affect nighttime sleep
no
drug interactions for Modafinil
Cytochrome P450
accelerates the metabolism of oral contraceptives, cyclosporine and certain other drugs
What is the typical drug of choice for children with ADHD
Methylphenidate (Ritalin, Concerta)
ADHD is characterized by
Inattention
hyperactivity
impulsivity
To make a diagnosis for ADHD…
symptoms must appear before age 7 and be present for at least 6 months
subclassifications of ADHD
predominantly inattentive type
predominantly hyperactive-impulsive type
combined type
In addition to drugs, what can be used for the management of ADHD
family therapy
parent training
cognitive therapy for child
second choice drugs for ADHD in kids
nonstimulants
atomoxetine
guanfacine
clonidine
first line treatment for ADHD in adults
methylphenidate (Ritalin, Concerta)
dexmethylphenidate (Focalin)
dextroamphetamine-amphetamine mixture (Adderall)
lisdexamfetamine (Vyvanse)
For ADHD with stimulants they do not create _____behavior; they only reduce ____ behavior
positive; negative
principle adverse affects of stimulants are
insomnia and growth suppression (secondary to appetite suppression)
what is a “drug holiday” with stimulants
some physicians recommend drug holidays on weekends and summers which creates opportunity for the growth to catch up. However, other clinicians argue against this because this can be hard on the kids. a rebound increase in growth will take place - as a result adult height may not be affected
Atomoxetine (Strattera)
approved for ADHD in adults and kids
first non-stimulant approved for ADHD
not regulated as a controlled substance
taken once a day
Adverse effects of Atomoxetine (Strattera)
GI (dyspepsia, n/v) reduced appetite dizziness somnolence mood swings trouble sleeping sexual dysfunction and urinary retention in adults angioneurotic edema - d/c drug and contact dr SI in children and adolescence weight loss and growth delay severe liver injury raise or lower bp hypotension syncope
what bowel cleaners are used for colonoscopy prep
sodium phosphate
a combination of sodium picosulfate, magnesium oxide and citric acid
PEG plus electrolytes
Polyethylene glycol-electrolyte solutions
(CoLyte, GoLYTELY) adverse effects
dehydration does not occur and electrolyte balance is preserved
nausea, bloating, abd discomfort
Are CoLyte and GoLYTELY safe for patients with electrolyte imbalances, heart failure, kidney disease or advanced liver disease
yes because they do not alter water and electrolyte status
what bowel prep laxative is not safe for heart failure, kidney disease, advanced liver disease or patients with electrolyte imbalances
sodium phosphate products. This is an osmotic laxative
What type of therapy is Phenytoin (Dilantin)?
What type of seizures is it approved for
monotherapy
partial seizures
primary generalized tonic clonic seizures
NOT absent seizures
Can you use Phenytoin (Dilantin) in pregnancy?
no
What precautions do you need to take when you give Phenytoin (Dilantin) IV
can cause severe hypotension and cardiac dysrhythmias. Cardiac monitoring should be used
What type of dosing considerations do you need for Phenytoin (Dilantin)?
Narrow therapeutic range
Non-linear relationship between dosing
What population do you need to avoid prescribing Phenytoin (Dilantin) to without specific testing
Asian population
CYP interactions may decrease effectiveness of what drugs when taking Phenytoin (Dilantin)?
oral contraceptives
warfarin
glucocorticoids (ie) prednisone, dexamethasone, hydrocortisone
what are some adverse effects for Phenytoin (Dilantin)
gingival hyperplasia
Dress syndrome
when is Fosphenytoin (Cerebyx) used
when PO Phenytoin is contraindicated. This is the IV formulation
What type of seizures is Carbamazepine (Tegretol) used for?
Tonic-clonic
simple partial
complex partial
When you compare Carbamazepine (Tegretol) to Phenytoin, which drug is preferred and why?
Carbamazepine (Tegretol) - less side effects
What is important to know about the pharm of Carbamazepine (Tegretol)
The half life decreases as the therapy progresses
initial treatment 40 hours
continued treatment 15 hours
what is the blackbox warning for Carbamazepine (Tegretol)
may cause serious skin reactions such as SJS and TEN
Aplastic anemia and agranulocytosis can occur
What population of people do you have to be cautious when giving Carbamazepine (Tegretol)
Asian population (test for HLA-B 1502
What adverse effects are important to know for Carbamazepine (Tegretol)
Bone marrow suppression aplastic anemia Water retention - caution with patients who have HF Hyponatremia monitor for DRESS Hepatic and renal failure
what do you need to tell your patient to watch for with Carbamazepine (Tegretol)
fever, sore throat, pallor, weakness, infection, easy bruising, petechiae - notify provider if these occur
What food should they avoid while taking Carbamazepine (Tegretol)
Grapefruit juice
What labs need to be monitored for Carbamazepine (Tegretol)
Na+
Hepatic
Renal
Blood counts
Avoid prescribing Valproic Acid (Depakene, Depakote) in children less than
2 years old
Can you give Valproic Acid (Depakene, Depakote) to someone who is pregnant?
no
What type of seizures can you prescribe Valproic Acid (Depakene, Depakote) for?
all of them
what is the blackbox warning for Valproic Acid (Depakene, Depakote)
Fatal hepatic failure has occurred. Young children and patients with mitochondrial disease are at increased risk. Fatal and rapidly progressing pancreatitis has occurred. Highly teratogenic
what are the symptoms for pancreatitis?
n/v
anorexia
abd pain
tell me about the therapeutic window for Valproic Acid (Depakene, Depakote)
wide
what are the most common side effects for Valproic Acid (Depakene, Depakote)
GI side effects - give enteric coated and take with food
what patient population can you not give Valproic Acid (Depakene, Depakote)
with decreased liver function - evaluate liver function at baseline and periodically
signs and symptoms of liver injury
reduced appetite malaise nausea abd pain jaundice
are CNS effects common for Valproic Acid (Depakene, Depakote)
no
what are the drug interactions for Valproic Acid (Depakene, Depakote)
combined with Topiramate = increased risk for hyperammonemia
Do not take with Carbapenem ABX -mero and imipenem can reduce plasma levels of valproic acid
signs and symptoms of hyperammonemia
vomiting
lethargy
altered LOC
altered cognitive function
what is Ethosuximide used for?
drug of choice for absence seizures
how many times per day do you take Ethosuximide
once per day but twice per day is better tolerated
how is Ethosuximide dosed
This is by monitoring clinical response. The balance is high enough to control the symptoms or the adverse effects become too great
adverse effects of Ethosuximide
systemic lupus erythematosus
leukopenia
aplastic anemia
SJS
Phenobarbital falls under what class of drugs?
Barbituates
What schedule class is Phenobarbital
Schedule IV
what type of seizures does Phenobarbital treat
partial and generalized tonic clonic
NOT absence
what is the metabolism of Phenobarbital
long half life - about 4 days
how long does it take to reach the plateau of Phenobarbital and why is that important?
2-3 weeks, loading doses are often given to increase serum levels
What problem should you avoid prescribing Phenobarbital having to do with familial history
avoid in pt with personal or familial history of porphyria
Don’t give Phenobarbital to patients with
resp compromise as it can cause resp depression
What vitamin deficiency is Phenobarbital linked to and what problems does this cause
Vit D, Vit K and calcium causing rickets and osteomalacia. eat foods high in vitamin D, K and calcium
symptoms of Phenobarbital tox
nystagmus
ataxia
generalized CNS depression
Death from resp depression
Drug interactions for Phenobarbital
CYP interactions decrease the effects of oral contraceptives and warfarin
Avoid other CNS depressants
When used with valproic acid can cause Phenobarbital levels to increase which could worsen adverse effects - decrease dose of Phenobarbital
Primidone is very similar to what drug?
Phenobarbital
what type of seizures is Primidone used for
tonic clonic
simple partial
complex partial
NOT absence
Primidone - monotherapy or adjunct?
adjunct therapy used usually with phenytoin or carbamazepine. NEVER use with phenobarbital
CNS effects Primidone
confusion in older adults
hyperactivity in children
sense of acute intoxication can occur after dosing
Primidone is contraindicated in
patients or family history of porphyria
adverse effects Primidone
acute psychosis
leukopenia
thrombocytopenia
systemic lupus
drug interactions Primidone
reduce the effects of oral contraceptives and warfarin
Risk with Zofran
prolongs QT interval
What should you monitor when giving zofran long term?
QT level and electrolytes
what two steroids are used to treat nausea but not FDA approved?
methylprednisonlone
and
dexamthasone
Aprepitant (Emend) pairs with what drugs when treating chemo induced n/v
dexamthasone and zofran
Aprepitant (Emend) Drug Interactions
rifampoin and phenytoin can decrease levels of emend
emend can raise levels of docetaxel, paclitaxel, etop, irinotecan, ifosfamide, imatinib, vinorelbine, vinblastine, and VCR, steroids (So reduce doses of steroids)
emend can decrease warfarin oral contraceptives
black box warning with phenergan
contraindicated in children below 2 years old
first line nausea in pregnancy
doxylamine and vitamin B6
n/v meds safe for bfing
phenergan
n/v meds to avoid in bfing
reglan, marinol,
n/v meds to avoid in older adults
benzo, scopolamine, reglan
when can you use methylpredisone in preg.
after 10 weeks gestation
why do they put atropine with lomotil?
to reduce the chance of abusing the drug
treating e.coli diarrhrea
cipro
treating e.coli in children and pregnant women
azithromycin
alosetron bbw
ischemic colitits
alosetron is contraindicated in pts with
severe constipation
intestinal obstruction
ischemic colitis
crohns disease
ulcerative colitis
diverticulitis
drug therapy for IBS
5-aminosalicylates glucocorticoids immunosuppressants immunomodulators abx
sulfasalazine use
5-aminosalicylates used for IBS reduces inflammation by reducing prostoglandin
sulfasalazine baseline labs
cbc
How is oxcarbazepine (Oxtellar XR, Trileptal) used?
monotherapy and adjunctive therapy for management of partial seizures
Is oxcarbazepine (Oxtellar XR, Trileptal) safe for kids?
yes used in adults in children
4 years and older for monotherapy
2 years and older for adjunctive therapy
adverse effect for oxcarbazepine (Oxtellar XR, Trileptal)
hyponatremia if combined with other drugs that reduce NA then you should monitor NA levels
If you are allergic to _______, you should not take oxcarbazepine (Oxtellar XR, Trileptal)
Carbamazepine
drug interactions for oxcarbazepine (Oxtellar XR, Trileptal)
If you combine with Perampanel or
phenobarbital and valproic acid
It can decrease your oxcarbazepine (Oxtellar XR, Trileptal) levels. Monitor levels closely
not recommended with Eslicarbazepine - can increase levels of Eslicarbazepine
birth control
oxcarbazepine (Oxtellar XR, Trileptal) and bone
decreased bone mineral density - osteopenia and osteoporosis with increased risk of fractures
Lamotrigine (lamictal) black box warning
may cause skin reactions such as SJS and TEN
what is Lamotrigine (lamictal) approved for
Adj therapy in adults and children older than 2
- generalized seizures associated with lennox-gastaut syndrome in adults and children
- primary generalized tonic clonic sizures in adults and children older than 2
monotherapy
- partial seizures in patients at least 16
Lamotrigine (lamictal) and psych
risk of SI is greater compared to other anti-seizure drugs
Gabapentin (Neurontin) is approved for
adjunctive therapy of partial seizures
is the absorption of Gabapentin (Neurontin) affected by food?
no
Gabapentin (Neurontin) and driving
avoid driving until tolerance develops
Gabapentin (Neurontin) drug interactions
it has none. Well combined with other drugs
Pregabalin (Lyrica) is used for
adjunct therapy of partial seizures
Pregabalin (Lyrica) has similar effects to _____ and is a schedule ____
Diazepam
Schedule V
Can you give Pregabalin (Lyrica) in pregancy
no
CNS effects of Pregabalin (Lyrica) and does it improve with time
Dizziness, somnolence - does not improve with time
Vision and Pregabalin (Lyrica)
Blurred vision, typically improves with time
other side effects of Pregabalin (Lyrica)
weight gain, concentration issues, headache, peripheral edema, dry mouth
Adverse effects Pregabalin (Lyrica)
Angioedema - d/c at the start of reaction
Rhabdomyolysis - d/c med
symptoms of rhabdomyolysis
muscle injury pain
tenderness
weakness
Abrupt d/c of Pregabalin (Lyrica)
insomnia
nausea
headache
diarrhea
withdraw slowly over one week
drug interactions for Pregabalin (Lyrica)
alcohol, opioids, benzodiazepines, and other CNS depressants may intensify the depressant effects of Pregabalin (Lyrica), so you should avoid
Levetiracetam (Keppra) approved for
myoclonic seizures in adults and adolescents 12 years and older
partial onset seizures in adults and children 4 and older
Primarily generalized tonic-clonic seizures 6 years old and older
side effects of Levetiracetam (Keppra)
possible like between keppra and renal injury
otherwise mild to moderate SE
most common: drowsiness and asthenia (lack of strength or weakness)
does not affect speech, cognition or other cognitive fx
drug interactions for Levetiracetam (Keppra)
There are none
can you use keppra in pregnancy
yes
Topiramate (Topamax) is approved for
Adj therapy of adults and children 2 years old and older with partial seizures, primary generalized tonic clonic seizures, and seizures associated with lennox gastaut syndrome
Monotherapy of adults and kids 10 yo and older with partial seizures or primary generalized tonic-clonic seizures
Topiramate (Topamax) adverse affects
can cause metabolic acidosis (hyperventilation develops)
prolonged use can lead to kidney stones, fractures, growth delay
angle closure glaucoma
what are the risk factors for Topiramate (Topamax)
pt with renal dx
severe resp disorders
diarrhea
ketogenic diet
What should the pt taking Topiramate (Topamax) do if they notice hyperventilation
notify the provider
their dose should be tapered slowly so you dont have rebound effects
What labs should be monitored periodically for Topiramate (Topamax)
Serum bicarb
signs of angle closure glaucoma
ocular pain, redness, vision changes
can you take Topiramate (Topamax) with pregancy
no
drug interactions for Topiramate (Topamax)
Phenytoin and carbamazepine can decrease levels of Topiramate (Topamax) by 45%
Increased risk for hyperamonia if given with valproic acid (encephalopathy)
Tiagabine (Gabitril) indications
partial seizures in pt at least 12yo
Tiagabine (Gabitril) drug interactions
levels of Tiagabine (Gabitril) can be decreased by Phenytoin, phenobarbital and carbamazepine
Zonisamide (Zonegran) indications
adjunct therapy of partial seizures in adults
Zonisamide (Zonegran) and driving
avoid driving
Zonisamide (Zonegran) and kidney patients
may effect kidneys, use in caution with patients that have kidney issues
Zonisamide (Zonegran) and fluids
drink 6-8 glasses of water per day
avoid grapefruit juice
labs for Zonisamide (Zonegran)
bicarb at baseline and periodically there after
drug interactions for Zonisamide (Zonegran)
st johns wort
phenytoin
phenobarbital
carbamazepine can all accelerate the metabolism of Zonisamide (Zonegran) which would reduce its half life
Felbamate (Felbatol) indications
adjuctive or monotherapy in adults with partial seizures
adjuctive therapy in children with lennox gastaut syndrome
Felbamate (Felbatol) black box warning
increased risk for aplastic anemia
may cause acute liver failure
