neuro Flashcards
what morphology do each of the following have? s. pneumo, h. flu, n. meningitides, ecoli/kleb/pseudo, listeria
s. pneumo (gm+ cocci), h. flu (gm - coccobacilli), n. meningitides (gm - cocci), ecoli/kleb/pseudo (gm - bacilli), listeria (gm + bacilli)
what is important to know about he CSF regarding meds you want to get there?
it flows unidirectionally–so injection into lumbar area isn’t best way to go–try to inject into ventricles
what increases penetration of meds into blood brain barrier?
low molecular weight, non ionized, meningineal inflammation, non protein bound, lipid soluble
which drugs have therapeutic levels in CSF, even without meningeal inflammation?
Sulfonamides/Trimethoprim Chloramphenicol Rifampin Metronidazole Isoniazid, Pyrazinamide, Ethionamide
which drugs have therapeutic levels in CSF with inflammation?
Penicillin G Nafcillin Cefotaxime Ceftriaxone Ceftazidime Imipenem Meropenem Vancomycin Linezolid Aztreonam Ciprofloxacin Fluconazole Ganciclovir Acyclovir
which drugs don’t have therapeutic levels even with inflamed meninges?
Aminoglycosides First generation cephalosporins Second generation cephalosporins Clindamycin Amphotericin o (except cefuroxime)
what are normal findings in CSF and what is found in bacterial meningitis?
(lab test, normal, csf) WBC (per mm3)
what are the likely meningitis pathogens in each of the following groups and empiric tx if gram stain not available? (hint: it needs to cover all those pathogens
tx goals of meningitis tx
Eradicate infection Improve signs and symptoms Prevent development of neurologic sequelae
what are the likely meningitis pathogens in each of the following groups and empiric tx if gram stain not available? (hint: it needs to cover all those pathogens 1-23 mo
1-23 months S. pneumoniae, N. meningitidis, Group B Strep, H. influenzae, E coli Vancomycin + third generation cephalosporin a
what are the likely meningitis pathogens in each of the following groups and empiric tx if gram stain not available? (hint: it needs to cover all those pathogens 2-50 yo
2-50 years N. meningitidis, S. pneumoniae Vancomycin + third generation cephalosporin a
what are the likely meningitis pathogens in each of the following groups and empiric tx if gram stain not available? (hint: it needs to cover all those pathogens >50
> 50 years S. pneumoniae, N. meningitidis, L. monocytogenes, gram-negative bacilli Vancomycin + ampicillin + third generation cephalosporin a
empiric tx of g+ diplococci
S. pneumoniae Ceftriaxone or Cefotaxime + Vanco + Dexamethasone
empiric tx of g- diplococci
N. meningitidis Ceftriaxone or Cefotaxime
empiric tx of g+ bacilli
L. monocytogenes Ampicillin +/- Gentamicin
empiric tx of g- bacilli
H. Influenzae, coliforms, P. aeruginosa  Ceftazidime or Cefepime +/- Gentamicin
targeted tx of group B strep and duration
Penicillin G or ampicillin for 14-21 days
targeted tx of H. Influenzae (G- bacilli)
ceftriaxone 7 days
targeted tx of n. meningitides and duration
ceftriaxone 7 days
targeted tx of group listeria and duration
Ampicillin +/- Gentamicin >21 days
targeted tx of s. pneomo and duration
depends on MIC, but Penicillin G or ampicillin for 10-14 days (add vanco or ceftriaxone if greater mIC)
indications for adding dexamethasone to abx tx for meningitis
Infants and children with Haemophilus influenzae type b meningitis (only if started before abx) Adults with pneumococcal meningitis (only if started before abx) Administer at 0.15 mg/kg q6 hours for 2-4 days 15 minutes before or with first antimicrobial dose
meningitis prophylaxis of close contacts
Haemophilus influenza type b Rifampin 600 mg po q24h x 4 days Neisseria meningitidis Ceftriaxone 250 mg IM x 1 or Rifampin 600 mg po q12h x 4 doses or Ciprofloxacin 500 mg po x 1 (if not resistant)
supportive care of viral enceaphalitis
Fluids Antipyretics/analgesics
what other med can be given to those with west nile or HSV encephalitis in addition to supportive cares?
anti seizures meds, tx for intracranial pressure and acyclovir
1 tx for seizure disorders
AED
what is the MOA of AED?
Effect sodium and calcium channels → stabilization of neuronal membranes Enhance inhibitory neurotransmission (GABA) Decrease excitatory neurotransmission (glutamate and aspartate) → Increased seizure threshold → Inhibition of the spread of abnormal (seizure) discharges
define concentration related and idiosyncratic adverse effects of AEDs and ways to manage them
Concentration-Related Most common Increased drug levels results in increased side effects Not permanent See at “peak” concentration or throughout day Management Lower dose/level Change schedule or formulation of medication Discontinue medication Idiosyncratic More rare Not related to dose/level May be permanent Seen throughout the day Management Discontinue the medication Treat adverse reaction as needed
what are some common chronic side effects of AEDs?
weight gain or loss, kidney stones, menstrual cycle irregularity, behavior changes, hirsutism, connective tissue changes, skin thickening
which drug has these chronic side effects? Behavior Δs Cerebellar syndrome Connective tissue Δs Skin thickening Folate deficiency Gingival hyperplasia Hirsutism Coarsening of facial features Acne Cognitive impairment Metabolic bone dz Sedation
phenytoin
what are common concentration dependent side effects of AEDs?
dizziness, drowsiness, lethargy, unsteadiness, sedation, GI distress, N/V, anorexia, somnolence, nervousness, weakness, blurred vision
the risk of suicide is _____ times higher in those on AEDs, esp if taking for seizures
two
what 3 possible drug intx are there with AEDs? how do you manage them?
antacids may decrease its absorption (take 2 hours before hand), highly protein bound drugs may compete and cause elevated free drug, CYP450 inducers or inhibitors (change dose accordingly)
what intx can cause the total serum concentration to increase?
removing an inducer, removing a competitor, adding an inhibitor,
what drugs are common inducers of cytochrome P450? (thus decreasing serum concentrations)
carbamezepine, phenytoin, phenobarbital, rifampin
what drugs are common inhibitors of CP450 (thus increasing serum drug concentrations)
cimetidine, cipro, erythromycin, clari, amiodarone, fluconazole, valproate, felbamate, ticlpidine, topiramate, zonisamide, propxyphene, ketoconazole
what drugs are rec’d for chronic tx of generalized tonic clonic seizures?
carbamazepine, lamotrigne, levetiracetam, oxycarbazepine, phenobarbital, phenytoin, valproate, topiramate, zonisamide
what drugs can be used to tx all kinds of seizures?
valproate, lamotrigine
what drugs are rec’d for all partial seizures?
same as generalized tonic clonic except not zonisamide and add gabapentin: carbamazepine, lamotrigne, levetiracetam, oxycarbazepine, phenobarbital, phenytoin, valproate, topiramate, zonisamide
how should # of seizures be monitored?
have them keep a seizure diary
what criteria must be met before d/cing a AED? how should d/cing be done?
All of the five following criteria must be met before considering discontinuation Seizure free for 2 to 5 years Normal neurologic exam Normal intelligence quotient Single type of partial or generalized seizure Normal EEG with treatment Slowly decrease polytherapy to monotherapy With monotherapy, slowly decrease AED over at least 1-3 months Decrease dose by no more than one-third each time
what tx is indicated 1st line (pre hospital) for status epileptics? 2nd line? 3rd line?
1st line: pR diazepam or iM midazolam. 2nd line: if not already given can give lorazepam and can repeat. 3rd line: phenytoin or fosphenytoin. if none of those work can give phenobarbital
carbamazepine: brand name MOA AE therapeutic range CYP450 inducer or inhibitor?
carbamazepine: brand name: tegretol MOA: na channel AE: diplopia, hyponatremia, leukopenia; Pg D therapeutic range: 4-12 mcg/ml inducer
gabapentin brand name MOA AE CYP450 intx?
gabapentin brand name: neurontin MOA: increase gabaingeric inhibition, decrease glutamate? not fully understood AE: Sedation, dizziness, ataxia, weight gain; behavior changes in children; potential for misuse & abuse CYP50: no
lamotrigne brand name MOA AE CYP459 intx?
lamotrigne brand name: lamictal MOA: na channel, decrease glutamate AE RASH, ataxia, tremor, sedation, nausea/vomiting, weight gain CYP450 inducer and inhibitor
phenobarbital brand name MOA AE therapeutic range CYP450 intx?
phenobarbital brand name: N/A MOA: increase GABA inhibition AE: SEDATION, Sedation, irritability, confusion, cognition and motor skills, aggression, hyperactivity therapeutic range CYP450: INDUCER
phenytoin brand name: MOA AE therapeutic range CYP450 intx?
phenobarbital brand name: dilantin MOA: na channel AE: Ataxia (cerebellar atrophy), nystagmus, osteoporosis, sedation, dizziness, gingival hyperplasia, hirsutism; Pg D therapeutic range: 10-20 mcg/ml free 1-2 mcg/ml CYP450 intx? inducer
felbamate brand name: MOA AE therapeutic range CYP450 intx?
felbamate brand name: felbatol MOA: excitatory AA inhibition AE: Anorexia, N/V, insomnia, HA, APLASTIC ANEMIA, HEPATIC FAILURE therapeutic range not defined CYP450 intx? complex
pregabalin brand name: MOA AE therapeutic range CYP450 intx?
pregabalin brand name:lyrica MOA: calcium channel AE: DIZZINESS somnolence, ataxia, blurred vision, WEIGHT GAIN, ABNORMAL THINKING therapeutic range; not defined CYP450 intx? none
topiramate brand name: MOA AE therapeutic range CYP450 intx?
topiramate brand name: topamax MOA: sodium channel, NMDA untag AE: lowed thinking, speech difficulties, DECREASED APPETITE AND COGNITION, HA, diplopia; Pg D therapeutic range CYP450 intx?
VALPROIC ACID brand name: MOA AE therapeutic range CYP450 intx?
VALPROIC ACID brand name: depakote MOA: chloride channel, gaba AE: Nausea/vomiting, TREMOR, ataxia, sedation, WEIGHT GAIN, HEPATIC FAILURE, THROMBOCYTOPENIA; Pg D therapeutic range 50-150 mcg/ml CYP450 intx? inhibitor
lorazepam brand name: MOA AE therapeutic range CYP450 intx?
lorazepam brand name: ativan MOA: increase GABA inhibition AE: SEDATION, ATAXIA, confusion therapeutic range CYP450 intx? none
fosphenytoin brand name: MOA AE therapeutic range CYP450 intx?
fosphenytoin brand name: cerebyx MOA: sodium channel AE NYSTAGMUS, DIZZINESS, ATAXIA; ECG or blood changes lower than with PHT therapeutic range CYP450 intx?
• Bleeding between inner skull table and dura • Appears “lenticular” on CT (football shaped) • Usually due to skull fx which tears middle meningeal artery (NOT VEIN) • Often little or no injury to underlying brain • May rapidly expand (b/c artery), causing herniation/death • Patient may “talk and deteriorate”- initially alert/talking then decompensates/herniates • If rapid surgical intervention (burr hole), prognosis is often excellent
epidural hematoma
• Focal hemorrhagic area on brain, often surrounded by edema • May occur on the side of skull impact or on the contralateral side of skull (contrecoup lesion) – brain hits the opposite side of the skull during impact
cerebral contusion
• a.k.a., parenchymal hemorrhage- bleeding within the brain • Due to torn blood vessels • May be delayed for days • Can produce expanding mass lesion
intracerebral hemorrhage
when you see battles sign behind the ear, raccoons eyes, and hemotympanum, or CSF out of nose what do you think of?
basilar skull fracture
when intracranial pressure rises what has to be displaced?
CSF, blood, brain
what is often calcified on CT in brain and can look like blood?
choroid plexus and pineal gland (central)
signs of tentorium herniation
- Ipsilateral fixed, dilated pupil 2. Contralateral weakness of arm/leg- corticospinal tract crosses at the lower brain stem 3. Deteriorating LOC
• Bleeding between dura and arachnoid/brain • Appears “sickle-shaped” on CT • Due to tears of bridging veins between cerebral cortex and dura • Greater frequency in elderly/alcoholics − Brain atrophy − Bridging veins span a greater distance, more easily torn • Often with severe underlying brain injury
subdural hematoma
signs of concussion
“mild traumatic brain injury”
Altered mental status, following blunt head trauma with or without LOC
May see LOC, confusion, memory loss, altered personality, focal neuro deficits
Duration usually short (seconds-minutes), but may last hours
Recovery usually complete
We take it a lot more seriously than we used to!
Initial impact of concussion called “coup” secondary impact called “contrecoup”
tx of concussion
Treatment of concussion
Cognitive and physical rest (no video games, TV, may have to take time off school—tx it like a sprained ankle that you try to avoid using for a while)
Ongoing neuropsych testing for persistent sx
Return to sports guidelines require
Complete clearing of all sx
Complete return of memory and concentration
No sx after provocative testing (jogging, situps, pushups)
Tearing/shearing of nerve fibers at time of impact
CT may be normal despite profound neurological deficit- can’t image on a cellular level
Results in prolonged, possibly permanent coma
Mortality 33%, usually due to cerebral edema
Death usually not right away, but with time and cerebal edema it can happen
diffuse axonal injury
post concussive syndrome
Persistent symptoms after head injury
May last weeks to months:
Persistent, recurrent Headache
Memory impairment
Concentration/attention problems
Anxiety, depression
Insomnia
Dizziness/ataxia
which head injury is associated with a Greater frequency in elderly/alcoholics b/c they have brain atrophy
may required very little trauma to cause it
subdural hematoma
what color is blood on CT?
bright white
indications for CT scan in head injuries
Shows hemorrhage, cerebral edema, skull fractures
Indications vary, generally include:
Prolonged LOC (>few seconds)
Persistent decreased mental status
Clinical suspicion of skull fracture
Persistent vomiting
Seizure
Focal neuro deficit (slurred speech, etc)
On Blood thinners
what imaging should also be done in someone with head injury?
c-spine
management of severe head injury
Severe Head Injury (if unresponsive, confused, etc)
ABC’s, C-spine immobilized (collar)
Intubate/hyperventilate to decrease pCO2 to 30-35 (if show signs of ^ ICP)
Elevate head of bed to 30 degrees
Correct hypotension if present
If focal deficits, suspect impending herniation
IV mannitol: an osmotic diuretic, decreases ICP
Emergent head CT
Significant mass lesion (EDH, SDH) need rapid neurosurgical evacuation
management of mild to moderate head injury
Observation (small chance could herniate)
Admit if:
Persistent decreased LOC
Focal neuro deficit,
Seizures
Unreliable pt. with hx of LOC
May discharge if:
Minor injury
Neurologically intact
Reliable family members to observe
most effective tx for PD
carbidopa/levodopa
carbidopa/levodopa
trade name
MOA
ae
MOA: increases DA in CNS o Levodopa (immediate precursor to DA) crosses BBB, DA doesn’t o Carbidopa inhibits peripheral conversion of levodopa DA (although not c
trade name: sinemet
titrate slowly to avoid N/V, hypotension
ae: Agitation, Confusion Insomnia, Psychosis Headache, Dizziness Orthostasis, Dyskinesias Nausea, Vomiting
Amantadine
trade name
MOA
AE
NMDA receptor antagonist; blocks glutamate transmission, promotes DA release, and blocks acetylcholine
Antiviral with mild therapeutic effects in PD
Sedation and confusion common; rebound PD if abrupt discontinuation
trade name: symmetrel
ae: Agitation, Confusion Insomnia, Psychosis Headache, Dizziness Orthostasis, Dyskinesias Nausea, Vomiting
MAO-B inhibitors: selegiline and rasagiline
trade names
MOA
AE
MOA: Prevent breakdown of DA (and othe neurotransmitters) via MAO-B; rasagiline may be neuroprotective and neurorestorative (2009 trial; needs verification)
trade names: selegiline: eldepryl; rasagiline: azilect
Drug/food interactions (rasagiline > selegiline):
o TCA, SSRI, SNRI, meperidine →CNS toxicity, autonomic instability, HTN, temp, death o MAOI → hypertensive crisis
o Tyramine-containing foods (dried, aged, fermented) → risk of hypertensive crisis
ae: Agitation, Confusion Insomnia, Psychosis Headache, Dizziness Orthostasis, Dyskinesias Nausea, Vomiting
catechol-o-methyltransferase (COMT inhibitors) entacapone and tolcapone
MOA
trade name
ae
MOA: Inhibit breakdown of levodopa
Increase half life of levodopa by 50% → more continuous stimulation of DA receptors
ae: Agitation, Confusion Insomnia, Psychosis Headache, Dizziness Orthostasis, Dyskinesias Nausea, Vomiting
trade name: entacapone: comtan; tolcapone: tasmar
which parkinsons med has dietary restrictions?
rasagiline: avoid tyramine containing foods like cheeses, wines, etc
what drug can delay need for use of levodopa in early disease or decrease the dose of levodopa in advanced d?
dopamine agonists like bromocriptine, pramipexole (mirapex)
dopamine agonists: pramipexole
trade name
AE
mirapex
AE:
Confusion, Dizziness Hallucinations, Orthostasis Nausea, Asthenia Syncope
Peripheral edema
signs of excess dopamine:
confusion, hallucinations, GI complaints, orthostatic hypotension, impulse control disorders d/t overstimulation of mesocorticolimbic DA pathways
anticholinergics: older tx of parkinsons
MOA
AE
example
MOA; Relative increase in striatal cholinergic activity tremor
ae: Confusion*, Memory loss* Anti-SLUD effects Sedation, Depression Orthostasis, Drowsiness
example: benztropine (cogentin)
how would you adjust dosing for someone whose dose seems to be “wearing off”
Decrease levodopa dosing interval by 30 to 60 minutes
Add COMT inhibitor if on levodopa (may require levodopa dose ) Add dopamine agonist to levodopa or vice versa
Add MAO-B inhibitor to levodopa
how would you help someone who has delayed on or “no on” response with parkinsons meds?
Give levodopa on empty stomach Use levodopa ODT
Avoid levodopa CR
Use apomorphine subcutaneous
how would you help someone who has start hesitation (“freezing”)
Increase levodopa dose
Add a dopamine agonist or MAO-B inhibitor
Utilize physical therapy along with assistive walking devices or
sensory cues (e.g., rhythmic commands, stepping over objects)
how would you help someone who is having peak-dose dyskinesia?
Decrease levodopa dose and add/increase DA agonist
Add amantadine
If COMPT inhibitor recently added, consider levodopa dose
drug used to tx hypomobility in parkinsons
apomorphine (apokyne)
T or F: there is no difference in the rate of motor complications between the levodopa formulations (CR and immediate release)
T
what are the only 2 drugs that are indicated for tx of PD psychosis and why? what is used to tx dementia?
only quetiapine rec’d, or maybe clozapine others may worsen it. to tx the dementia; consider donepizil or rivastigmine
tx for acute flares of MS
coticosteroids and plasmaphoresis
first line tx for MS?
interferons or glatiramer
B interferons
mOa
EXAMPLES
monitoring
ae
Interferon -1a: Avonex, Rebif; Peginterferon -1a: Plegridy Interferon -1b: Betaseron & Extavia
MOA: alter the expression and response to surface antigens, can augment suppressor cell function, suppress T-cell proliferation, may ↓ BBB permeability
Decrease frequency of exacerbations and delay disability
First line DMT based on tolerability and efficacy
monitoring:
EDSS (Kurtzke Expanded Disability Status Scale; 0-10) + neuro exam every 3 mo during 1st yr then every 6 mo
Baseline CBC, plt, LFT, then @ 1 month, then q3 months x 1 yr, then q6 months thereafter
(some can cause leukopenia and anemia, LFtS)
ae: HA, flu-like sx, myalgia, ISR
glatiramer:
trade name
indication:
MOA
AE
glatiramer:
trade name copaxone
indication: RR MS
MOA: inhibits t cells
AE: with injection: ISR, chest pain, flushing, difficilty breathing, anxiety
fingolimod
indications
MOA
AE
MOA: prevents some WBCs from migrating to CNS and subsequent damage
Indication: RR, PR
Efficacy: modestly better than Avonex at preventing relapses (Pharmacist’s Letter, 2010)
Adverse Effects: HA, LFTs, HR, block (ECG with 1st dose), macular edema, bronchitis,
pneumonia, rare PML; avoid in pts with recent MI, angina, stroke, TIA, or severe HF
Dose:0.5mgpoqd
Cost: $5000/month ($60,000/yr) (Pharmacist’s Letter, 5/13)
Comparable in efficacy to first-line drugs
which drugs for MS are not first line (interferon and glatiramer) but have comparable effiacy to first line?
fingolimod, teriflunimide, dimethyl fumarate
teriflunomide (aubagio)
indication
moa
ae
Teriflunomide (Aubagio) Note: Leflunomide (Arava) is a prodrug of teriflunomide
MOA: may involve a reduction in the number of activated lymphocytes in the CNS
Indication: approved to treat the relapsing forms of MS
Adverse Effects: nausea, diarrhea, hair loss, hepatotoxicity (black box warning), infection risk
o Teratogenic: reliable contraception needed for women of child bearing potential
Monitoring: LFTs baseline, qmonth x 6 months, then periodically
Dose: 7 mg or 14 mg po once daily
Cost: $3750/month ($45,000/yr) (Pharmacist’s Letter, 5/13)
dimethyyl fumarate (tecfidera)
moa
indication
ae
monitoring
Dimethyl fumarate (Tecfidera)
MOA: appears to protect neurons and myelin and have anti-inflammatory effects
Indication: approved to treat the relapsing forms of MS
Adverse Effects: flushing, nausea, diarrhea most common; decreased WBC; rare PML in RA tx
Monitoring: WBC baseline, q3-6 months initially, then periodically
Dose:120mgpobidx7days,then240mgpobid
Cost: $4575/month ($54,900/yr) (Pharmacist’s Letter, 5/13)
Comparable in efficacy to first-line drugs
mitoxantrone
MOA: suppression of immune cells that attack the body
Indication: approved to ↓ the frequency of relapses and/or neurologic disability in adults with
SPMS, PRMS, or worsening RRMS
• Not considered a replacement for Interferons or glatiramer but often used in conjunction
Adverse Effects: ↓ WBC & plts, anemia, ↑ LFTs, ↓ LVEF, HF (max lifetime dose of 140 mg/m2), UTIs, N/V, mucositis (Black box warning: cardiotoxicity, acute myelogenous leukemia)
Monitoring: LVEF evaluation baseline, before each subsequent dose, after a cumulative dose of 100 mg/m2 has been reached, and if signs or sx of HF develop
Dose: 12 mg/m2 by IV infusion over 5-15 minutes every 3 months
Cost:~$1500/dose($6,000/yr)(Pharmacist’sLetter,11/12)
Reservedforpatientswithworseningdiseasebecauseofcardiactoxicity,riskofAML
natalizumab
Natalizumab (Tysabri)
MOA: partially humanized monoclonal antibody directed at α4β-integrin (aka VLA-1); prevents
activated lymphocytes from passing across BBB
Indication:monotherapyforrelapsingformsofMStodelayphysicaldisabilityandrelapsesin
patients who have a documented inadequate response or intolerance to traditional MS therapies
AdverseEffects:rarePML(progressivemultifocalleukoencephalopathy);risk~1/1000pts
treated x 18 months (Neurology, 2008;71:766–773); patients followed in an ongoing safety
registry (TOUCH), hepatotoxicity
Dose:300mgIV(asinfusion)every4weeks
Cost: $3,800/dose ($45,600/yr) (Pharmacist’s Letter, 11/12)
Reservedforpatientswhocan’ttolerateordon’trespondtoothertherapiesduetoriskofPML
and hepatotoxicity
alemtuzumab
Alemtuzumab (Lemtrada) (Pharmacist’s Letter, 5/15)
MOA: may alter the number, proportions, and properties of some lymphocyte subsets
Indication:optionforrelapsing-remittingformsofMS;maybemoreeffectivethaninterferon
AdverseEffects:Autoimmuneorthyroiddisorders,infections,hypersensitivityreactions,
nausea, infusion-associated reactions, potential for PML; requires special registration for health
care facility and patient to ensure adequate follow-up
Dose:IVinfusionyearly
Cost:notavailable
Used for patients who don’t respond adequately to interferon beta or other disease-modifying
therapies
drugs for spasticity in MS
Baclofen
Dantrolene
Diazepam
Tizanidine
Tiagabine
Gabapentin Pregabalin
Botulinum toxin type A Dalfampridine
tx of fatigue in mS
Amantadine (Symmetrel) 100 mg BID
Can cause nausea, insomnia, hallucinations, and livedo reticularis, a purplish discoloration of the skin.
Modafinil (Provigil) 100-200 mg BID
Can cause headache, nausea, and insomnia.
Methylphenidate (Ritalin) 10-20 mg early am and noon
Second-line therapy. Can cause weight loss, anorexia, irritability, and insomnia. Caution with heart disease.
Fluoxetine (Prozac) 20-40 mg QD
Can be useful when patients also have depression.
SSRIs (Celexa, Luvox, Paxil, Prozac, Zoloft)
Can also help with fatigue.
tx of vertigo in mS
Meclizine (Antivert) 25 mg Q6H
Can cause sedation.
Scopolamine patch (Transderm Scop) Q3 days
Can cause dizziness and dry mouth.
Ondansetron (Zofran) 4-8 mg TID
TX OF TREMOR IN MS
Propranolol (Inderal) LA 80-320 mg daily
Greatest effect for limb and hand tremor.
Primidone (Mysoline) 100-250 mg TID to QID
Can cause sedation.
Gabapentin (Neurontin) 300-600 mg TID
Can cause fatigue & ataxia. Titrate slowly to sedation.
