Neuro Flashcards
what are the cholinergic effects?
constricted pupils increased saliva bronchoconstriction increased GI mucous bladder fundus contraction
what are the adrenergic (anticholinergic) effects?
dry mouth dilated pupils increased contractility increased HR bronchodilation bladder fundus relaxes, sphincter contracts
what are the parasympathetic effects on the autonomic nervous system?
pupils constrict eyes become dry mouth waters heart rate slows down breathing sloes bronchial passages constrict digestive functions stimulated stomach/intestine activity increases bladder contracts
what are the sympathetic effects on the autonomic nervous system?
pupils dilate eyes water, tears form mouth becomes dry sweating increases heart rate increases adrenaline rush breathing quickens bronchial passages dilate digestive functions inhibited stomach/intestine activity decreases bladder relaxes
what are the classifications of cholinergic drugs?
parasympathomimetic
what are the classifications of cholinergic blocking drugs?
parasympatholytic
anticholinergic
antimuscarinic
what are the classifications of adrenergic drugs?
sympathomimetic
what are the classifications of adrenergic blocking drugs?
sympatholytic
what are the main uses of cholinergic drugs?
decreases IOP in glaucoma
treat atony of GI tract and urinary bladder
diagnose and treat myasthenia gravis
physostigmine used to treat anticholinergic toxicity
not organ specific- other organs not targeted become ADR
what are the cholinesterase inhibitors used to treat MG?
neostigmine
pyridostigmine
what are the cholinesterase inhibitors used to treat Alzheimer’s?
donepezil (Aricept)
galantamine (Razadyne)
rivastigmine (Exelon)
memantine (Namenda)- not a cholinesterase inhibitor
what is the mainstay of MG treatment?
reversible cholinesterase inhibitors
is MG treatment for symptom management or curative?
symptom management
which medications are used to treat MG?
neostigmine
pyridostigmine
which medications are used to treat Alzheimer’s?
donepezil (Aricept)
rivastigmine (Exelon)
memantine (Namenda)
what are the benefits to taking donepezil (Aricept) in comparison to other AD drugs?
has a better side effect profile
longer duration of action
GI effects are usually self resolving
which forms is rivastigmine (Exelon) available in?
patch and liquid
which class of drugs are the treatment of choice for Parkinson’s disease?
dopaminergics
what is the MOA of dopaminergics?
attempt to restore the functional balance of dopamine and acetylcholine in the corpus striatum of the brain
which medications are used in the treatment of Parkinson’s?
amantadine (Symmetrel) bromocriptine (Parlodel) levodopa (L-dopa, Larodopa) carbidopa-levodopa (Sinemet) pramipexole (Mirapex) ropinirole (Requip) rotigotine (Nuepro)
what are the ADRs of dopaminergics?
N/V
hallucinations
confusion
when using dopaminergics, how long does it take for there to be therapeutic effects?
may need up to 6 months to achieve maximum effects
dopaminergics have many drug interactions and the variation depends on what?
variations with each drug
what kind of education would you give to patients taking dopaminergics?
avoid abrupt d/c
drug interactions
TCA’s decrease the effects
may increase effects of HTN drugs
what should be monitored in pts taking dopaminergics?
lab tests pertaining to hepatic and renal function
“on-off” phenomenon (suddenly symptoms worsen/improve)
what are the FIRST LINE drugs for treatment of PD?
Bromocriptine (Parlodel)
Pergolide (Permax)
Pramipexole (Mirapex)
Ropinirole (Requip)
when symptoms of PD worsen, what should be introduced?
levodopa
which drugs are used to control tremors in PD by relaxing smooth muscle?
cholinergic blockers
what are factors that precipitate seizures?
sleep deprivation high caffeine intake hyperventilation stress hormonal changes sensory stimuli drug/alcohol use infections fever metabolic disorders
which off-label use are anticonvulsants being used for?
treatment of mood disorders
what is the MOA of antiseizure medications?
stimulating an influx of chloride ions (usually associated with GABA)
delaying an influx of Na
delaying an influx of Ca
which anticonvulsant medications fall under the classification of hydantoins?
Ethotoin (Peganone)- not common
Fosphenytoin (Cerebyx)- NOT for primary care (available only in IM or IV dosing)
Phenytoin (Dilantin)- (capsules (ER), chewable tablets, suspension, injection)
hydantoins are first line treatment for what?
tonic-clonic seizures
partial complex seizures
what is the MOA of hydantoins?
Works by stabilizing neuronal membranes and decreasing seizure activity by increasing efflux or decreasing efflux of sodium ions across cell membranes in the motor cortex
(onset and duration vary)
since hydantoins are metabolized in the liver, what will cause the levels of the drug to increase?
cimetidine diazepam acute alcohol intake valproic acid allopurinol
since hydantoins are metabolized in the liver, what will cause the levels of the drug to decrease?
barbituates
antacids
calcium
chronic alcohol use
what are the drug interactions for hydantoins?
decreased effect of: carbamazepine estrogens acetaminophen corticosteroids levodopa sulfonylureas cardiac glycosides
what are the MOST COMMON ADRs of hydantoins?
nystagmus dizziness pruritus paresthesia HA somnolence ataxia confusion HYPOtension tachycardia N/V anorexia constipation dry mouth gingival hyperplasia urinary retention urine discoloration
which patients should be monitored closely when taking hydantoins?
patients with renal and liver disease
which routes should hydantoins never be administered in a primary care setting?
IV or IM
in regards to monitoring for hydantoins, what should be monitored?
baseline labs, plasma levels, & TSH
need to assess OTC drugs (ibuprofen, antacids)
which anticonvulsant medications fall under the classification of iminostilbenes?
Carbazepine (Tegretol, Tegretol XR, Carbatrol)
Oxcarbazepine: (Trileptal)
Valproic acid (Depakote, Depakene)
what is the MOA for iminostilbenes?
depresses neuron transmission in the neucleus ventralis anterior of the thalmus; has the ability to induce its own metabolism
why do iminostilbenes have a black box warning?
for causing blood dyscrasias
how are iminostilbenes absorbed/metabolized?
absorbed through the stomach
metabolized in the liver
what are the ADRs of iminostilbenes?
depression of bone marrow liver damage impairs thyroid function drowsiness dizziness blurred vision N/V dry mouth diplopia HA
the levels of iminostilbenes increases with concurrent use of which medications?
propoxyphene (Darvocet) cimetidine erythromycyn clarithromycin verapamil hydantoins
the plasma levels of which drugs decrease with concurrent use of iminostilbenes?
beta blockers warfarin doxycycline succinimides heloperidol
which food/beverage should be avoided when taking iminostilbenes?
grapefruit
when are succinimides used?
for treatment of absence seizures in children and adults
which anticonvulsant medications fall under the classification of succinimides?
Ethosuzimide (Zarontin)
Methsuximide (Celontin)
what is the MOA of succinimides?
suppress seizures by delaying calcium influx into neurons
decreases nerve impulses and transmission in the motor cortex
how are succinimides absorbed/metabolized?
absorbed in the GI tract
metabolized in the liver
what are the ADRs of succinimides?
GI most common somnolence fatigue ataxia agranulcytosis aplastic anemia granulocytopenia
which anticonvulsant medications fall under the classification of GABA?
Gabapentin (Neurontin)
Tiagibine (Gabitril)
Topiramate (Topamax)
GABAs are pregnancy category what?
D
what are the most common ADRs of GABA?
somnolence
other CNS efects
what should be monitored in patients taking GABA?
frequency/severity of seizure activity mood changes depression anxiety DO NOT d/c abruptly
which anticonvulsant medications fall under the classification of levetiracetam?
Leviracetam (Keppra)
when is levetiracetam used?
adjunct partial onset seizures
what is the possible neuropsychiatric ADR of Keppra?
suicidality
when is lemotrigine (Lamictal) used?
in the adjunctive treatment of primary generalized tonic-clonic seizures and partial seizures in adults and children greater than or equal to 2 yrs
lamotrigine is used concurrently with what medications?
valproic acid
phenytoin
the levels of lamotrigine are decreased by what?
barbituates
estrogens
phenytoin
the levels of lamotrigine are increased by what?
alcohol
carbabazepine
CNS depressants
valproic acid
where is lamotrigine metabolized?
in the liver and kidneys
what are the ADRs of lamotrigine?
mostly GI N/V constipation chest pain peripheral edema somnolence fatigue dizziness anxiety insomnia HA amblyopia nystagmus
why does lamotrigine have a black box warning?
SJS
what should patients taking lamotrigine be educated about?
adherence avoid alcohol avoid OTC meds adequate hydration report any new drugs report ADRs
what are the classes of sedative hypnotics?
nonbenzodiazepine
benzodiazepine
ramelteon (Rozerem)
what are the non-benzodiazepine medications?
zolpiden (Ambien)
zaleplon (Sonata)
eszopiclone (Lunesta)
what are the benzodiazepine medications?
flurazepam (Dalmane)
temazepam (Restoril)
triazolam (Halcion)
which medications are considered stimulants?
amphetamine
dextroamphetamine
adderall (mix of amphetamine & dextro salts)
non-amphetamine: atomoxetine (Strattera)
which of the stimulant medications is not considered a schedule II drug?
Strattera
when dosing stimulants, what is usually the starting dosage FORM?
IR
what is the peak incidence of migraine headaches?
age 25 to 34 yrs
what are the four types of migraines?
complex, multifactoral
migraine with aura (classic migraine)
migraine without aura (common migraine)
complicated migraine
what is the pathophysiology of migraine HAs?
changes in serotonin causes release of vasoactive neurotransmitters
causes inflammatory response
excitatory serotonin receptors activated
serotonin receptor agonists abort migraines by stimulating inhibitory serotonin receptors
what are the goals of migraine treatment therapy?
minimize the impact on quality of life
avoid medication overuse
what are the OTC analgesics (work best early in migraine) used to treat migraines?
ibuprofen
naproxen
migraine formulas- OTC combinations
what are the mid-range analgesics used to treat migraines?
Butalbital/ASA or APAP (Fiorinal or Fioricet)- controlled substance
Isometheptene/acetaminophen/dichloralphenazone (Midrin)- schedule IV
what are the high-range analgesics (opioids) used to treat migraines?
PO codeine combined with ASA or APAP
IM meperidine – not a good option
Intranasal butorphanol (Stadol)
when are high-range analgesics the drug of choice to treat migraines?
in pregnancy
when vasoconstrictors are contrindicated
when pt is non-responsive to ergotamine or serotonin agonsits
which vasoconstrictor (ergots) medications are used to treat migraines?
ergotamine
DHE
how is DHE administered?
IM or intranasal
which serotonin 5-HT antagonists or triptans are used to treat migraines?
Almotriptan (Axert) Eletriptan (Relpax) Frovatriptan (Frova) Naratriptan (Amerge) Rizatriptan (Maxalt) SUMAtriptan (Imitrex) ZOLMitriptan (Zomig)
what are the contraindications to taking to triptans?
CAD
uncontrolled HTN
pregnancy
triptans have drug interactions with which medications?
ergotamines
MAOIs
SSRIs
when are triptans taken?
at the onset of migraine
why are antiemetics co-administered with migraines?
N/V common in migraines
co-administer with abortive medication
which antiemetics are used with migraines?
Metoclopramide (Reglan)
Prochlorperazine (Compazine)
when is preventative therapy for migraine patients considered?
for patients with more than 2 migraines per month
which medications are used in preventative therapy?
Beta Blockers (propranolol, timolol – FDA approved, nadolol, metoprolol and atenolol are also used)
Tricyclic antidepressants
Antiepileptic drugs
which is the beta-blocker of choice in migraine prevention?
propanolol
which beta-blockers should be used in pts with asthma or respiratory concerns?
metoprolol
atenolol
what are the ADRs of propanolol?
fatigue
lethargy
depression
which TCAs are used for migraine prevention?
Amitriptyline (Elavil)
what are the ADRs of Elavil?
drowsiness
weight gain
constipation
which antiepileptics are used for migraine prophylaxis?
Divalproex (Depakote)
Gapapentin (Neuronton)
Topiramate (Topamax)
how does Depakote help in migraine prophylaxis?
decreases the number and intensity of the migraine
depakote is pregnancy category what?
D
how should neuronton be dosed?
start low and titrate up over 4 weeks to target dose
how should topiramate be dosed?
dose titrated up over 4 weeks
what are the ADRs of topiramate?
weight loss
somnolence
kidney stones
which NSAIDs are used to treat menstrual migraines?
naproxen BID (started a week before menses and continued for a week later)
which CCBs can be used to treat migraines?
verapamil for pts with HTN who cannot tolerate beta-blockers
what are the nonpharmacological forms of tx for migraines?
identifying triggers
alternative therapies
ice biofeedback
what are the alternative therapies used in migraine treatment?
migranol (feverfew, riboflavin, magnesium, vitamins) acupuncture aromatherapy hypnosis reflexology massage yoga
how can migraines be monitored?
HA diary
medication refills
BP monitoring
if on divalproex, need liver function and CBC tested
what are tension HAs?
band-like pressure, persistent dull pain
not worsened by exercise
last from 30 minutes to days
what is the preventative therapy for tension HAs?
beta-blockers
TCAs
non-pharmacologic therapy
when is preventative therapy considered for tension HAs?
considered if more than one or two HA per week
what are the non-pharmacologic therapies used for tension HAs?
stress management
biofeedback
exercise
acupuncture
tension HAs do not respond to which medications?
triptans
ergots
what is the cause of transformed migraines?
overuse of analgesics
coexisting psychopathology
which medications are used to treat cluster HAs?
100% O2
ergotamine derivatives
intranasal lidocaine
sumatriptan
which medications are used in preventative therapy for cluster HAs?
ergotamine
verapamil
divalproex
lithium
what should be avoided to decrease cluster HAs?
all alcohol
tobacco
stress
vigorous activity
what should be monitored with cluster HAs?
for suicidal thoughts
keep HA diary
what is medication overuse HA?
drug rebound HA reclassified by the IHS as medication overuse
what are the criteria for medication overuse HA?
HA present >15 days/mth
regular overuse of drugs for acute HA for >3 mths
HA has gotten worse during therapy
resolves or reverts to previous pattern after overused medication d/c
what are the stages of therapy in medication overuse HAs?
withdrawal from offending drugs
transition and support during detoxification
preventative therapy
when should preventative therapy start for medication overuse HAs?
at beginning of withdrawal
2 to 3 weeks before
after withdrawal
