Module 5: Unit C Migraines,Gout, Fibro

Question 1

What is the difference between acute/abortive versus prophylactic treatment of migraines?

Answer 1

Abortive is stopping the headache. Prophylactic is preventing frequency, reducing length and intensity (2+ per week).

Question 2

Abortive treatments for migraine

Answer 2

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)

Question 3

Indication for prophylactic migraine medication

Answer 3

> 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

Question 4

Triptans (serotonin 1B/1D receptor agonist) Example

Answer 4

Sumatriptan (Imitrex)

Question 5

Sumatriptan (Imitrex) indication

Answer 5

Acute/abortive treatment of migraines

Question 6

MOA Imitrex

Answer 6

Selective activation of 5ht receptors suppresses the release of CGRP

Question 7

Safety Sumatriptan (Imitrex)

Answer 7

Potential for coronary vasospasm

D2D with other triptans, ergots, MAOIs, SSRIs, SNRIs (agonist amplifies and we can give them too much serotonin).

Question 8

Contraindications for Sumatriptan (Imitrex)

Answer 8

Ischemic Disease and MI

Question 9

Ergot alkaloids Example

Answer 9

Dihydroergotamine

Ergotamine

Question 10

Indication Ergot alkaloids

Answer 10

acute treatment of migraines

Question 11

MOA ergot alkaloids

Answer 11

Alters transmission at serotonergic, dopaminergic, and a-adrenergic junctions. Causes constriction of cranial arteries.

Question 12

Contraindications and D2d for Ergot

Answer 12

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.

Question 13

BBW ergot

Answer 13

Potent inhibitors of CYP3A4 can raise levels posing a risk of vasospasm. Cerebral or peripheral ischemia can occur.

Question 14

Side effect of ergot

Answer 14

Can stimulate nausea and vomiting.

Question 15

Ditan Lasmiditan (Reyvow) indication

Answer 15

acute treatment of migraines

Question 16

Ditan Lasmiditan (Reyvow) MOA

Answer 16

Activating the 5 HT1F receptors inhibits the release of neuropeptides and neurotransmitters and inhibits the pain pathway.

Question 17

Safety with Ditan Lasmiditan (Reyvow)

Answer 17

Schedule V controlled substance (C-V) has abuse potential.

CNS depression and driving impairment.

Question 18

calcitonin gene-related peptide (CGRP) antagonists example

Answer 18

Ubrogepant (Ubrelvy)

Question 19

Indication for Ubrelvy

Answer 19

acute treatment of migraines

Question 20

MOA Ubrelvy

Answer 20

calcitonin gene-related peptide (CGRP) antagonists

Question 21

Side effects with Ubrelvy

Answer 21

The most common side effects are Central nervous system: Drowsiness (2% to 3%)

Question 22

Beta-Blockers examples for prophylaxic migraines

Answer 22

Propranolol (Inderal)

Atenolol (Tenormin)

Question 23

Indication for beta blockers

Answer 23

Migraine prophylaxis (angina, HTN, cardiac dysrhythmia, heart failure, symptoms of hyperthyroidism)

Question 24

Safety with BB

Answer 24

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.

Question 25

BBW beta-blockers

Answer 25

Abrupt discontinuation may exacerbate angina and increase the risk of MI.

Question 26

Pregnancy and lactations use of BB for headaches

Answer 26

Excreted in breastmilk. Not recommended in pregnancy or lactation.

Question 27

Headaches Preventive- AEDs example

Answer 27

Divalproex (Depakote), Topomax

Question 28

Indication Depakote

Answer 28

Seizure disorders, bipolar disorder, and migraine prevention.

Question 29

MOA depakote

Answer 29

May augment inhibitory effects of GABA

Question 30

Side effects and contraindicatinos of depakote

Answer 30

Nausea, fatigue, weight gain | Contraindicated in pregnancy.

Question 31

BBW depakote:

Answer 31

Potentially fatal pancreatitis and hepatitis. Neural tube defects in developing fetus.

Question 32

Example TCAs

Answer 32

Nortriptyline (Elavil)

Question 33

Indication TCAs Nortriptyline (Elavil)

Answer 33

Migraine prevention, Depression, Fibromyalgia, neuropathic pain

Question 34

MOA Elavil

Answer 34

Block reuptake of NE and 5-HT

Question 35

Side effects TCAs (Elavil)

Answer 35

``` Orthostatic hypotension Anticholinergic effects Diaphoresis Sedation Cardiac toxicity seizures ```

Question 36

BBW TCA

Answer 36

May increase the risk of suicide.

Question 37

CGRP receptor antagonist example

Answer 37

Erenumab (Aimovig) | One a month injection)

Question 38

Indication of Aimovig

Answer 38

Prevention of migraine headache

Question 39

MOA Erenumab (Aimovig)- immunomodulator

Answer 39

Binds to and antagonizes the function of the CGRP receptor to decrease inflammation.

Question 40

Indication botox

Answer 40

Migraine prevention for those with 15+ per month.

Question 41

MOA botox

Answer 41

Neurotoxic protein. Prevents the release of acetylcholine at neuromuscular junctions

Question 42

BBW botox

Answer 42

It can spread from the injection site and produce muscle weakness, difficulty with respiration and swallowing, and can be life-threatening

Question 43

Indication for Colchicine (Colcrys)

Answer 43

Gout prevention and acute treatment

Question 44

MOA Colchicine (Colcrys)

Answer 44

anti-inflammatory agent thought to be due to its ability to decrease the infiltration of leukocytes into the joint cavities

Question 45

Safety/D2D/Contracindications for Colchicine (Colcrys)

Answer 45

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

Question 46

Xanthine oxidase inhibitors example

Answer 46

Allopurinol (Zyloprim)

Question 47

Indication Allopurinol (Zyloprim)

Answer 47

Chronic tophaceous gout

Question 48

MOA Allopurinol (Zyloprim)

Answer 48

Inhibits XO (required for uric acid formation)

Question 49

Safety/Side effects with Allopurionl (Zyloprim)

Answer 49

Rare bone marrow suppression, hepatotoxicity, and hypersensitivity

Question 50

Uricosuric agent example

Answer 50

Probenecid (Probalan)

Question 51

indication Probenecid (probalan)

Answer 51

gouty arthritis

Question 52

Safety/D2D Probenecid (probalan)

Answer 52

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.

Question 53

Recombinant uric acid oxidase (IV) example

Answer 53

(Pegloticase (Krystexxa)

Question 54

Indication for Pegloticase (Krystexxa)

Answer 54

Severe, treatment-refractory, chronic gout.

Question 55

MOA Pegloticase (Krystexxa)

Answer 55

Reduces uric acid levels by converting it to allantoin, a water-soluble compound easily excreted by the kidneys.

Question 56

Safety Pegloticase (Krystexxa)

Answer 56

Hemolysis and methemoglobinemia have been reported with pegloticase in patients with G6PD deficiency.

Question 57

Fibromyalgia SNRI example

Answer 57

Milnacipran (Savella) | Duloxetine (Cymbalta)

Question 58

Indication Milnacipran (Savella)

Answer 58

Depression, anxiety, Fibromyalgia

Question 59

MOA Savella

Answer 59

Boost serotonin and norepinephrine

Question 60

Fibromyalgia Anticonvulsant example

Answer 60

Pregabalin (Lyrica)

Question 61

indication Lyrica

Answer 61

Epilepsy, neuropathic pain, Fibromyalgia, general anxiety disorder

Question 62

MOA Lyrica

Answer 62

Inhibits release of neurotransmitters

Question 63

Safety/D2D Lyrica

Answer 63

Scheduled V Potential physical dependence Drug to-drug interactions: alcohol, benzos, CNS depressants

Question 64

What is the difference between acute/abortive treatment of gout and prophylactic treatment of gout?

Answer 64

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.

Question 65

What should we do to a warfarin dose if a patient is on Allopurinol (Zyloprim)?

Answer 65

Lower it!

Question 66

What is the level of evidence for prescribing muscle relaxants to patients with Fibromyalgia?

Answer 66

Level B

Question 67

What is the level of evidence for prescribing opioids to patients with Fibromyalgia?

Question 68

List the three FDA-approved drugs for the treatment of Fibromyalgia?

Answer 68

Cymbalta, Lyrica, Savella

Question 69

Topiramate (Topamax)

Answer 69

Broad spectrum anti seizure used for migraine prevention.

Question 70

Safety with Topomax

Answer 70

Paresthesia, fatigue, cognitive dysfunction | Drug-to-drug interactions with phenytoin and carbamazepine.