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Pharm Exam 3 Spring > misc > Flashcards

misc Flashcards

1
Q

Parkinson’s mechanism

A

Loss of pigmented cells in substantia nigra - make and store dopamine

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2
Q

L-Dopa

A

1st line
Most effective for symptomatic relief
Usually for >65

DO NOT stop abruptly
Wearing off phenomenon: 50% of pts

Incr risk of hip fractures d/t homocysteine

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3
Q

Dopamine Agonists

A

No response to L-Dopa: Dopamine agonists ineffective

Bromocriptine (ergot derivative)

Pramipexole
Ropirinole
Apomoprhine
Rotigotine (patch)

Decrease milk production

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4
Q

Bromocriptine

A

Dopamine Agonist, ergot derivative

SEs: stroke, szs, AVH, hypotension, HTN, MI, GI bleed, pulmonary fibrosis, LFTs elevation

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5
Q

Pramipexole

A

Dopamine Agonist

Take to d/c: NMS

Renally adjusted, EPS, hypotension, rhabdo, AVH
CNS depression, hypotensive effects

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6
Q

Apomorphine

A

Intermittent or continuous infusion/injection

NO ZOFRAN! severe hypotension and loss of consciousness
Premed w/ trimethobenzamide

Test dose; monitor BP and Scr

SEs: AVH, sudden sleep, ortho hypotension/syncope/dizziness, MI, headache, rhinorrhea, edema

QT prolongation

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7
Q

MAO B Inhibitors

A

Early PD
Only modest symptomatic relief

Selegiline (more SEs?), Rasagiline (adjunct), Safinamide (adjunct)

Serotonin syndrome!

Caution: HTN, high tyramine foods, cardiovascular dz, etoh

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8
Q

COMT Inhibitors

A

Entacapone (prolong L dopa)

Tolcapone (prolong central L-Dopa breakdown. Red: hepatotoxicity, orthostatic hypotension)

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9
Q

Anticholinergics in Parkinsons

A

Artane (trihexyphenidyl) - most widely used

Cogentin (Benzotropine), may also inhibit dopamine reuptake

Propantheline (peripheral): drooling, urinary freq

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10
Q

Amantadine

A

Antiviral? with mild antiparkinson activity
MOA uncertain
More effective than anticholinergics

best as short term monotherapy

SE: livedo reticularis

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11
Q

Pimavanserin

A

Tx of hallucinations/delusions with parkisonian psychosis

Atypical antipsychotic, inverse agonist/antagonist activity at 5-HT2A/C

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12
Q

Alzheimers pathophys

A

Shortage of Ach
Neurofibrillary tangles - tau protein intracellular
neuritic plaques: extracellular amyloid beta

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13
Q

Alzheimers Dx

A

No bio marker

Thorough testing: Hx, MMSE, exclude other possible causes

Start Tx ASAP!

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14
Q

Donepezil

A

Reversible/non comp inhibition; ACHe inhibitor
Mild-mod AD

Titration Q 4-6 weeks

Amiodarone will increase level
B block: risk of AV block
NSAIDs: risk of GI bleed

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15
Q

Rivastigmine

A

Mild-mod AD
Inhibits AchE and butrylrylcholinesterase (sp) - broader efficacy

PO or Patch

DDI: bradycardia (b blcok), cholinergic effects (pyridostigmine), lowers sz threshhold

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16
Q

Galantamine

A

Mild-mod AD
Inhibits AchE and modulates nicotinic receptors: increase ACH release
Increased release of glutamate and serotonin

Bradycardia, cholinergic, lowers sz threshold

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17
Q

NMDA receptor antagonist

A

Memantine

Noncompetitive inhibitor, blocks glutamate from overstimulating NMDA receptors.

Moderate/severe AD

Acetazolamide, amiloride: reduce memantine excretion
Dextromethorphan: increase SEs

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18
Q

Red flags in HA

A

SNOOP

Systemic
Neurologic
Onset - new/sudden
Other associated conditions
Previous HA Hx - serverity
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19
Q

Migraine Abortive

A 
NSAIDs
APAP or w/ caffeine 
Triptans
Ergots
Gepants
Ditans
Antiemetics
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20
Q

Migraine preventative - established efficacy

probably effective

A 
Candesartan (lisinopril)
VPA
Frovatriptan
Metop,propan,timolol (atenolol, nadolol)
Topamax
(memantine, venlafaxine, amitriptyline)

others:
gabapentin, lamictal, verapamil/amlodipine, ami/nortriptyline

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21
Q

Hemicrania continua/paroxysmal hemicrania

A

Indomethacin

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22
Q

Cluster abortive

A

Triptans + O2

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23
Q

Cluster prevention

A

Verapamil!
Topamax
Glucocorticoids, lithium

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24
Q

Triptans

A

Inhibit release of vasoactive peptides –> vasoconstriction –> block pain pathways

Stimulate serotonin 1b/1d: inhibit dural nociception

Contraindications:
Cardiac: ischemic, vasospasm/angina, WPW, arrhythmias, peripheral vascular dz, uncontrolled HTN

Stroke: migraine/basilar/hemiplegic; ischemic bowel, cerebrovascular dz

SEs: vasospasm, MI, VT/VF, stroke, somnolence, N/V, CP/pressure/tightness, neck/jaw pain

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25
Q

Triptans general

A

Inhibit release of vasoactive peptides –> vasoconstriction –> block pain pathways

Stimulate serotonin 1b/1d: inhibit dural nociception

Contraindications:
Cardiac: ischemic, vasospasm/angina, WPW, arrhythmias, peripheral vascular dz, uncontrolled HTN

Stroke: migraine/basilar/hemiplegic; ischemic bowel, cerebrovascular dz

SEs: vasospasm, MI, VT/VF, stroke, somnolence, N/V, CP/pressure/tightness, neck/jaw pain

General caution w/: ergot deriviatives, MAO-AIs

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26
Q

Triptans specific

A

Sumatriptan: PO x1, may repeat in 2hours
(half life 2.5 hours)

SC: 1-6mg x1, may repeat in 2 hours. more efficacious than PO, fastest onset
Nasal: less SEs, unpleasant taste

Zolmitriptan: PO, Nasal spray, ODT
serotonergic effects

Naratriptan: slower onset, lower efficacy

Rizatriptan (Maxalt)
Caustion w/ propanolol! increases riza level by 70%

Almotriptan: contraindicated w/ ergots/triptans w/in 24 hours, strong serotonergic.

Eletriptan: most likely to produce short term and sustained benefit. 3A4 substrate, avoid within 72 hours after 3a4 inhibitors

Frovatriptan: slower onset, lower efficacy

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27
Q

Ergots

A

5HT 1b/d receptor agonists (like triptans)

Ergotamine: poor PO bioavailability (2%)
Avoid: CAD, PVD, HTN, hepatic/renal
DDI: avoid with 3a4 inhibitors: life threatening peripheral ischemia nad vasospasm

Dihydroergotamine
Alpha blocking: weaker arterial vasoconstrictor
More potent venoconstrictor and fewer SEs than ergotamine
No physical dependence or rebound headache

IV, IM, SC, NS

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28
Q

CGRP

A

Calcitonin gene related peptide
Most prevalent neuropeptide in trigeminovascular system

Alpha: cerebral
Beta: gut

very potent vasodilator in cerebral

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29
Q

Gepants

A

CGRP ANTAgonists. Prevent vasodilation.

Rimegepant: acute/proph

Atogepant: prophylaxis only

Urbogepant: acute only

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30
Q

CGRP

A

Calcitonin gene related peptide
Most prevalent neuropeptide in trigeminovascular system

Alpha: cerebral
Beta: gut

very potent vasodilator in cerebral

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31
Q

5HT1F Agonists

A

“Ditans” - lasmiditan

Inhibits trigeminal nerve firing. Acute HA only. 1 dose in 24 hours. 50-200mg PO x2

No driving w/in 8 hours
Caution with CNS depressants/ETOH/older

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32
Q

Migraine MABs

A

IV q3mo: eptinezumab, IgG1

SubQ Q mo: galcanezumab, IgG4

SubQ q month OR q3 months: Fremanezumab IgG2
^ acts as anti cgrp antibodies

IgG targets CGRP receptors: SubQ qmonth, Erenumab

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33
Q

Absence seizures tx

A

Ethosuximide - 1st line
w/ other seizure types: VPA, lamictal, topamax

DO NOT: tegretol, gabapentin, tiagabine, pregabalin

34
Q

Tonc/atonic/myoclonic/tonic-clonic sz

A

Lamictal, VPA, topamax, tegretol, trileptal

35
Q

General/unclassified seizure treatment

A

VPA, lamictal, topamax

36
Q

Focal onset

A 
Carbamazepine
Cenobamate/lacosamide?
Lamotrigine
Oxcarbazpeine
Topiramate

Adjunct: Keppra, Tiagabine, Gabapentin
Cenobamate/lacosamide?

37
Q

Keppra

A

Selectively prevents hypersynchronization

SEs: Leukopenia, pancytopenia, hyponatremia. Withdrawal seizures if abrupt DC
Binds to resins/polymers
T1/2: 6-8hrs

38
Q

Zonisamide

A

Blocks Na/Ca channels, suppress hypersyncrhonization, inhibits carbonic anhydrase

T1/2: 63h

SEs: SJS, TEN, agranylocytosis, angle closure glaucoma, psychosis, rhabdo

39
Q

Vigabatrin

A

REMS program d/t vision loss

inhibits GABA degradation - partial seizures or refractory complex

Progressive permanent bilateral concentric visual field constriction

Baseline, then 4week, then q3 months until 3-6 months after D/c

40
Q

Vestibular suppressants

A

Metoclopramide (D2 blocker)

Prochlorperazine (D2 blocker)

Dimenhydrinate - dramamine
Meclizine (central anticholinergic)
Promethazine (antihistamine, antimuscarinic, etc)

Diazepam
Valium

41
Q

Myasthenia Gravis Immune Tx

A

Acute immunomodulation: IVIG, plasma exchange

Short term immunosuppression: Prednisone

Long term immunosuppression:
Azathioprine (first line)
MTX (second line)
Mycophenolate mofetil (third line)
Tacrolimus (third/fourth line)

Last: Ciclosporin, Cyclophosphamide
LAST last: rituximab

42
Q

Diagnostic tests for Myasthenia Gravis

A

Ab against Ach receptor (Achr-ab) - first test
Ab against MuSK - nonresponsive to Mestinon
6-12% sero negative: most likely pure ocular dz

Other: electrophysiologic test; RNS, SFEMG
CT, MRI

Ice pack test if ptosis

43
Q

Pyridostigmine (Mestinon)

A

PO q8 for MG

SE: cholinergic crisis/bradycardia
arrhythmias/hypotension
GI

44
Q

Fingolimide

A

2nd line

MOA: sequester lymphocytes; sphingosine 1 phosphate receptor modulator

Check EKG prior to dosing, end of observation. Watch for brady for at least 6 hours (possibly overnight)

Contraindicated: 1a or III antiarrhythmics (amiodarone)

Siponimod - 1st line (no need for 6hr monitoring)

45
Q

Novantrone / Motoxantonre

A

Cumulative lifetime dose

last line? for MS

46
Q

REMS for JCV

A

Natalizumab

47
Q

CD20?

CD52?

A

20:
Rituximab (mouse; less favorable)
Ocrelizumab
Ofatumumab

52: Alemtuzumab

48
Q

MS in pregnancy - know

A

Cat B: Glatiramer,!! oxybutynin, SSRI

D: Azathioprine, clabridibe, cyclophosphamide, mitoxanthrone

X: MTX, teriflunomide

49
Q

Prophylaxis for Alemtuzumab

A

Herpes - Acyclovir

PJP - Septra

50
Q

Ampyra / dalfamipride

A

Block K+
Improves walking in MS

DDI: NO CIMETIDINE / h2 blockers –> seizures

51
Q

Drugs to avoid in MG

A

Abx: aminoglycoside, fluoroquinolones, macrolides, “quins”

B-blocks, Botox, Statins
Contrast

Sorta steroids (“paradoxical exacerbation”) - first 2 weeks

52
Q

DMF

A

Dimethyl Fumarate for MS (similar: MMF )

Neuroprotective and immunomodulatory, antioxidant

Check CBC baseline and annually - lymphocytopenia - d/c

53
Q

Teriflunomide

A

Preg Cat X

Inhibits pyrimidine synthesis: disrupts T cells interacting with antigen presenting cells

Hepatotoxicity (main problem), diarrhea

DDI: phenytoin (incr level of phenytoin, decrease level of teriflunomide)

live vaccines, dexamethasone, immunosuppressants

54
Q

Lines of tx for MS

A

Moderate DMT first line: Siponimod, DMF

2nd line: fingolimod, clabridine (2/3rd)

ozanimod??

55
Q

Injectable modestly (low) effective for MS (interferons)

A

Interferons:
1a (“animal”, mammalian: avonex (weekly IM), rebif (SC TIW), plegridy (SC q2 weeks)

1b (“bacteria”, e. coli: betaseron (SC every other day), extavia

DDI: drugs lowering sz threshold (buprion, clozapine, abx, propofol, theophylline), drugs causing depression (phenobarb, topamax, steroids, tamoxifen)

pancytopenia, depression, lft elevation
injection site rxn, flu like sx, abd pain

other modestly effective MS –> GLATIRAMER (not interferon)

56
Q

GLATIRAMER

A

Random polymer - modest (low)
Decoy for immune system
relatively mild SEs: tachy, lipoatrophy, flue like, flsuhing, sob, anxiety

57
Q

Highly effective MS tx

A

Alemtuzumab - 1st
Ocrelizumab - 1st
Ofatumumab - 1st

Natalizumab - 2nd
Mitoxantrone - obsolete - 2nd/3rd

58
Q

Cladribine

A

DMT for MS, prodrug

DNA breakdown

2nd/3rd line
2 cycles/year for 2 years
Lymphocytes must be wnl for 1st cycle, >800/ml 2nd cycle (ALC)

BBW: malignancy, teratogencicity

59
Q

Anti inflammatory T cell

A

T helper 2

60
Q

IM Interferon for MS

A

Avonex

61
Q

Verapamil

A

Non dihydropyrdine

depresses cardiac conduction + contractility

62
Q

Atropine

A

Inhibits acetylcholine

Improves cholinergic crisis if given

63
Q

Sz meds affecting voltage dependent Na+ channels

A

Lamictal
Topamax
Oxcabazepine, eslicarbazepine

Zonisamide, lacosamide, rufinamide

64
Q

Binds to alpha 2 delta subunit of Ca+ channels

A

Pregabalin

Gabapentin

65
Q

Inhibits gaba reuptake?

Irreversibly inhibits GABA metabolism

A

Tiagabine

Vigabatrin

66
Q

AMPA receptor blocker

A

Permpanel

67
Q

Triptan w/ longest half life

A

Frovatriptan

68
Q

Exacerbates absence seizures

A

Carbamazepine, + (gabas) gabapentin, tiagabine, pregabalin

69
Q

Tegretol / Carbamazepine

A

MOA unknown

epilepsy, trigeminal neuralgia, mood

Screen for genetics: risk of SJS or TEN

risk aplastic anemia, agranulocytosis

CYP 3a4 inducer and substrate

70
Q

Antiseizure which increases GABA effects and inhibits glutamade/NMDA receptor

A

Depakote - hepatotoxicity, SIADH, wt gain, rash, photosensitivity

71
Q

Topamax

A

inhibits CAH enzyme –> metabolic acidosis

SJS, Kidney stones

72
Q

Cholinergic receptor w/ faster response time

A

nicotinic

73
Q

Postganglionic fibers ANS

A

sympathetic: long
parasympathetic: short

74
Q

Botox mechanism

A

Irreversibly block Ach vesicle release –> muscle paralysis

75
Q

Azathioprine

A

purine antagonist, inhibits DNA synthesis/cell proliferation

76
Q

Supportive care in MS

A 
Dalframpridine
Muscle relaxants (antispastic - baclofen)
Amantadine (reduce fatigue)
Antidepressants
Analgesics
PT, Exercise
77
Q

Acute attacks in MS

A

prednisone: HIGH dose: 500-2000mg/day x 3-5 adys

methylprednisolone IV: 500-1000mg/day x 3-5 days

Acthar gel: adrenocorticotropic analogue if cannot tolerate high dose steroids
80-120 units IM/SQ Qday x 2-3 weeks

Plasmapharesis

78
Q

Other NMDA ANTagonists

A

Dextrometorphan, ketamine, methadone

79
Q

Do not use zofran with

A

Apomorphine

use trimethyl benzamide (Tigan)

80
Q

Gepant prophylaxis AND acute

A

Rimegepant (all gepants PO)

81
Q

tension HA tx

A

abortive: NSAIDS, APAP, caffeine, triptans
prophylaxis: TCA

82
Q

MOA Natalizumab

A

IgG targets alpha4 subunit of integrins on leukocytes –> INHIBITS cell adhesion

300mg IV over 1 hour q4 weeks

Pharm Exam 3 Spring (1 decks)

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