Module 5: Unit C Migraines,Gout, Fibro Flashcards
What is the difference between acute/abortive versus prophylactic treatment of migraines?
Abortive is stopping the headache. Prophylactic is preventing frequency, reducing length and intensity (2+ per week).
Abortive treatments for migraine
Triptans – selective serotonin receptor agonists (5-HT1)
Ergot alkaloids (ergotamine & dihydroergotamine (DHE)
Ditan- 5HT1F receptor agonist (CV)
Oral CGRP receptor antagonist
Analgesics (Opioids, NSAIDs, acetaminophen (Tylenol)
Indication for prophylactic migraine medication
> 2/month
Attacks last > 24 hours
Cause major disruptions in ADLs with disability of 3 or > days
Abortive therapy fails or is overused
Symptomatic medications are contraindicated or ineffective.
Use of abortive meds > two times/week.
Migraine variants produce profound neurologic effects
Triptans (serotonin 1B/1D receptor agonist) Example
Sumatriptan (Imitrex)
Sumatriptan (Imitrex) indication
Acute/abortive treatment of migraines
MOA Imitrex
Selective activation of 5ht receptors suppresses the release of CGRP
Safety Sumatriptan (Imitrex)
Potential for coronary vasospasm
D2D with other triptans, ergots, MAOIs, SSRIs, SNRIs (agonist amplifies and we can give them too much serotonin).
Contraindications for Sumatriptan (Imitrex)
Ischemic Disease and MI
Ergot alkaloids Example
Dihydroergotamine
Ergotamine
Indication Ergot alkaloids
acute treatment of migraines
MOA ergot alkaloids
Alters transmission at serotonergic, dopaminergic, and a-adrenergic junctions. Causes constriction of cranial arteries.
Contraindications and D2d for Ergot
Pregnancy- can cause uterine contractions and abortion. Cateogry X.
Renal and hepatic impairment.
CAD, PVD, and uncontrolled hypertension.
CYP3A4 inhibitors.
Do not use with triptans.
BBW ergot
Potent inhibitors of CYP3A4 can raise levels posing a risk of vasospasm. Cerebral or peripheral ischemia can occur.
Side effect of ergot
Can stimulate nausea and vomiting.
Ditan Lasmiditan (Reyvow) indication
acute treatment of migraines
Ditan Lasmiditan (Reyvow) MOA
Activating the 5 HT1F receptors inhibits the release of neuropeptides and neurotransmitters and inhibits the pain pathway.
Safety with Ditan Lasmiditan (Reyvow)
Schedule V controlled substance (C-V) has abuse potential.
CNS depression and driving impairment.
calcitonin gene-related peptide (CGRP) antagonists example
Ubrogepant (Ubrelvy)
Indication for Ubrelvy
acute treatment of migraines
MOA Ubrelvy
calcitonin gene-related peptide (CGRP) antagonists
Side effects with Ubrelvy
The most common side effects are Central nervous system: Drowsiness (2% to 3%)
Beta-Blockers examples for prophylaxic migraines
Propranolol (Inderal)
Atenolol (Tenormin)
Indication for beta blockers
Migraine prophylaxis (angina, HTN, cardiac dysrhythmia, heart failure, symptoms of hyperthyroidism)
Safety with BB
Avoid it in patients with severe allergies- because it blocks epinephrine.
Mask symptoms of hypoglycemia.
Can worsen heart failure and asthma.
It can result in bradycardia, reduced cardiac output, precipitation of heart failure, AV block, Bronchoconstriction, and hypoglycemia.
BBW beta-blockers
Abrupt discontinuation may exacerbate angina and increase the risk of MI.
Pregnancy and lactations use of BB for headaches
Excreted in breastmilk. Not recommended in pregnancy or lactation.
Headaches Preventive- AEDs example
Divalproex (Depakote), Topomax
Indication Depakote
Seizure disorders, bipolar disorder, and migraine prevention.
MOA depakote
May augment inhibitory effects of GABA
Side effects and contraindicatinos of depakote
Nausea, fatigue, weight gain
Contraindicated in pregnancy.
BBW depakote:
Potentially fatal pancreatitis and hepatitis. Neural tube defects in developing fetus.
Example TCAs
Nortriptyline (Elavil)
Indication TCAs Nortriptyline (Elavil)
Migraine prevention, Depression, Fibromyalgia, neuropathic pain
MOA Elavil
Block reuptake of NE and 5-HT
Side effects TCAs (Elavil)
Orthostatic hypotension Anticholinergic effects Diaphoresis Sedation Cardiac toxicity seizures
BBW TCA
May increase the risk of suicide.
CGRP receptor antagonist example
Erenumab (Aimovig)
One a month injection)
Indication of Aimovig
Prevention of migraine headache
MOA Erenumab (Aimovig)- immunomodulator
Binds to and antagonizes the function of the CGRP receptor to decrease inflammation.
Indication botox
Migraine prevention for those with 15+ per month.
MOA botox
Neurotoxic protein. Prevents the release of acetylcholine at neuromuscular junctions
BBW botox
It can spread from the injection site and produce muscle weakness, difficulty with respiration and swallowing, and can be life-threatening
Indication for Colchicine (Colcrys)
Gout prevention and acute treatment
MOA Colchicine (Colcrys)
anti-inflammatory agent thought to be due to its ability to decrease the infiltration of leukocytes into the joint cavities
Safety/D2D/Contracindications for Colchicine (Colcrys)
Nausea, vomiting, myelosuppression myopathy
Colchicine can cause rhabdomyolysis, especially if the patient is on a statin.
Do not take with P-GlycoProtein inhibitors (amiorderone, procardia, etc.) or CYP3A4 inhibitors (erythromycin…)
do not use it during pregnancy
Xanthine oxidase inhibitors example
Allopurinol (Zyloprim)
Indication Allopurinol (Zyloprim)
Chronic tophaceous gout
MOA Allopurinol (Zyloprim)
Inhibits XO (required for uric acid formation)
Safety/Side effects with Allopurionl (Zyloprim)
Rare bone marrow suppression, hepatotoxicity, and hypersensitivity
Uricosuric agent example
Probenecid (Probalan)
indication Probenecid (probalan)
gouty arthritis
Safety/D2D Probenecid (probalan)
may precipitate or worsen any current acute attacks: do not start it until the acute attack has resolved.
Hypersensitivity reactions may occur, and there is a risk of this drug causing renal stones.
Do not take aspirin with Probenecid, as its mechanism of action is reduced if combined.
Recombinant uric acid oxidase (IV) example
(Pegloticase (Krystexxa)
Indication for Pegloticase (Krystexxa)
Severe, treatment-refractory, chronic gout.
MOA Pegloticase (Krystexxa)
Reduces uric acid levels by converting it to allantoin, a water-soluble compound easily excreted by the kidneys.
Safety Pegloticase (Krystexxa)
Hemolysis and methemoglobinemia have been reported with pegloticase in patients with G6PD deficiency.
Fibromyalgia SNRI example
Milnacipran (Savella)
Duloxetine (Cymbalta)
Indication Milnacipran (Savella)
Depression, anxiety, Fibromyalgia
MOA Savella
Boost serotonin and norepinephrine
Fibromyalgia Anticonvulsant example
Pregabalin (Lyrica)
indication Lyrica
Epilepsy, neuropathic pain, Fibromyalgia, general anxiety disorder
MOA Lyrica
Inhibits release of neurotransmitters
Safety/D2D Lyrica
Scheduled V
Potential physical dependence
Drug to-drug interactions: alcohol, benzos, CNS depressants
What is the difference between acute/abortive treatment of gout and prophylactic treatment of gout?
The medications for gout are used to relieve the pain (acute) and then to help lessen the occurrence (prophylactic) of another gouty attack by lowering the uric acid levels.
What should we do to a warfarin dose if a patient is on Allopurinol (Zyloprim)?
Lower it!
What is the level of evidence for prescribing muscle relaxants to patients with Fibromyalgia?
Level B
What is the level of evidence for prescribing opioids to patients with Fibromyalgia?
List the three FDA-approved drugs for the treatment of Fibromyalgia?
Cymbalta, Lyrica, Savella
Topiramate (Topamax)
Broad spectrum anti seizure used for migraine prevention.
Safety with Topomax
Paresthesia, fatigue, cognitive dysfunction
Drug-to-drug interactions with phenytoin and carbamazepine.
