Neuro Exam 3 Flashcards
(180 cards)
1
Q
REM sleep
A
-paradoxical sleep
-brain is electrically + metabolically activated
-muscles are paralyzed
-occurs in bursts w/ 62-173% increase in cerebral blood flow
-controlled by cholinergic cells in the mesencephalic, medullary + pontine gigantocellular areas
-dramatic physiologic change from NREM
2
Q
NREM sleep
A
-quiescent sleep
-3 stages
-dreaming is rare
-muscles are not paralyzed
-controlled by the basal forebrain, lower brain stem to the thalamus + hypothalamus
3
Q
What chemicals control wakefullness?
A
-NE
-acetylcholine
-histamine
-serotonin
-dopamine
-orexin/hypocretin
4
Q
What chemicals control sleepiness?
A
-adenosine
-GABA
-melatonin
5
Q
What chemicals control NREM?
A
-GABA
-adenosine
6
Q
what chemicals control REM?
A
acetylcholine
7
Q
what is the BBW for benzos?
A
-benzos & opioids may result in porfound sedation, respiratory depression, coma + death
- use of benzos exposes users to risk of abuse, misuse + addiction = overdose or death
8
Q
What is the BBE for z-drugs?
A
-complex sleep behaviors, including sleep-walking, sleep driving, + engaging in other activities while not funny awake
**d/c immediately if pt. experiences a complex sleep behavior
9
Q
class side effects of Z-drugs
A
-use w/ caution in the elderly, drowsiness, dizziness, confusion, risk of falls, avoid use w/ alcohol, withdrawal symptoms upon abrupt d/c (tremor, muscle cramps, seizures)
10
Q
Estazolam indication
A
-sleep onset or sleep maintenance insomnia
–> short term management of insomnia characterized by difficulty falling asleep, frequent nocturnal awakenings, and/or early morning awakenings
11
Q
Estazolam SEs & CIs
A
SE: hypokinesia
CIs: pregnancy or with itraconazole or ketoconazole
12
Q
Eeszopiclone (Lunesta) facts
A
-excellent for sleep maintenance or early morning awakenings –> approved for sleep onset or sleep maintenance insomnia
-can be used long term, up to 6 months
13
Q
Eszopiclone (Lunesta) SEs
A
-MAJOR CYP3A4 substrate (monitor when using with ketoconazole, itraconazole)
-SEs: headache, dysgeusia, nervousness/anxiety, xerostomia, infection, stomach upset
14
Q
Zaloplon (Sonata) facts/uses
A
-ultra short-acting, rapid onset
-avoid taking after a high-fat meal (delays absorption)
-approved for short-term tx of insomnia (up to 30 days)
**does NOT reduce nighttime awakening
15
Q
Zaleplon (Sonata) SEs
A
-excreted in breast milk
-SEs: headache, nausea, abdominal pain
-MAJOR CYP3A4 substrate: interactions with cimetidine, rifampin etc
16
Q
Zolpidem (Ambien) formulations
A
-IR tab: sleep onset, off label for sleep maintenance
-ER tab: sleep onset or sleep maintenance
-SL tab: take if more than 4 hours remain before waking and pt has trouble returning to sleep
17
Q
Zolpidem (ambien) SEs
A
-rapid onset, short 1/2 life
-avoid use in severe hepatic impairment
SEs: headache, nausea (min tolerance and rebound at rec dosages)
18
Q
Trazadone facts
A
-may improve sleep continuity; off-label use
-useful in pts with a hx of substance abuse and/or depression
19
Q
Trazodone SEs
A
BBW: suicidal thoughts and behaviors
SEs: carryover sedation and alpha adrenergic blockade
-priapism is a rare side effect
- when d/c, gradually taper the dose over 2-4 weeks
20
Q
Suvorexant (Belsomra) facts
A
-turns off wake signaling, assists in getting to sleep and maintaining sleep
-onset of action: <30 mins
21
Q
Suvorexant (Belsomra) SEs
A
-interactions with CYP3A4 inhibitors/inducers
-SEs: drowsiness, dizziness, headache, sleep paralysis, abnormal dreams, URTI
**Ci in narcolepsy
22
Q
Lemborexant (DayVigo) facts
A
-turns off wake signaling, assists in getting to sleep and maintaining sleep
-doses to 5-10 mg at bedtime with at least 7 hours before planned time of awakening
23
Q
Lemborexant (DayVigo) side effects
A
-next-day drowsiness and increased risk of falling –> CNS depression may persist for up to several days after d/c
SEs: drowsiness, dizziness, headache, complex sleep behaviors, abnormal
CI in narcolepsy
24
Q
Ramelteon (Rozerem) facts
A
-induces sleepiness, regulates circadian rhythm
-approved for treatment of sleep-onset insomnia and for long-term use
25
Ramelteon (Rozerem) SEs
-do not use in pts with severe liver disease
-not as effective in pts who have already been treated a BZDRA
-side effects: headache, dizziness, somnolence
**CI with fluvoxamine
**not a controlled substance
26
Melatonin
-dose of 3 to 5 mg in the evening over 4 weeks (lower doses in elderly pts)
-beneficial effects on sleep-onset latency, shift workers and jet lag
**not recommended for use in pts with Alzheimer's disease
27
Doxepin facts
-TCA
-indicated for sleep maintenance insomnia
-inhibits reuptake of serotonin and NE
-BBW: for suicidality
*take with with food --> slower absorption --> next-days somnolence
** do not take within 3 hours of a meal
28
Insomnia pharmacotherapy for the elderly
-CBT-I
-Ramelteon
-Eszopiclone
-Zolpidem
-low - dose doxepin
29
Insomnia Pharmacotherapy for the pregnant
-diphenhydramine
-doxylamine
-low -dose doxepin
30
Types of sleep apnea
-central: impairment of respiratory drive
-obstructive: upper airway collapse and obstruction
-Mixed: both CSA and OSA
31
Obstructive sleep apnea standard of tx
-nasal positive airway pressure during sleep --> can be administered continuously (CPAP)
-weight management
-avoid all CNS depressants and drug that cause weight gain
32
Narcolepsy facts
-tetrad: excessive daytime sleepiness, cataplexy, hallucinations, sleep paralysis
-loss of normal function of hypocretin-orexin NT system
33
Narcolepsy tx
-good sleep hygiene and scheduled daytime naps
-avoidance of drugs that can worsen daytime sleepiness
-focus on tx of excessive daytime sleepiness, cataplexy, and REM sleep abnormalities
*modafinil or armodafinil are standard for EDS
34
Modafinil (Provigil)
-used for EDS in narcolepsy
-AEs: headache, nausea, anxiety/nervousness, dizziness, dyspepsia, xerostomia, back pain, rhinitis
35
Armodafinil (Nuvigil)
-AE: headache, insomnia, dizziness, nausea, xerostomia
36
Both modafinil and armodafinil
-avoid use in pregnancy
-**may decrease effectiveness of contraceptives
-use with cautions in pts with cardiovascular disease, use is not recommended in pt with a hx of left ventricular hypertrophy
37
Solriamfetal (Sunosi)
-CI with use of MAOi
-AEs: headache, anxiety, insomnia, decreased appetite, nausea
-avoid use in pts with unstable cardio disease, arrhythmias
38
Pitolisant (Wakix)
-CI in severe hepatic impairment
-may prolong QT (avoid use in pts with known arrhythmias)
-AEs: headache, anxiety, musculoskeletal pain. URI
39
Sodium oxybate (Xyrem)
BBWs: CNS depression, abuse/misuse, restricted access
**dosed at bedtime after patients is in bed with second dose 2.5 to 4 hours later
AEs: confusion, headache, dizziness, weight loss/decreased appetite, urinary incontinence, drowsiness, depression, somnambulism, anxiety
40
Medications for Cataplexy in Narcolepsy
-Fluoxetine
-Venlafaxine
-Atomoxetine
-Clomipramine
-Imioramine
-Nortiptyline
-pitolisant
-sodium oxybate
41
Circadian rhythm disorders
-presents as either insomina or hypersomnia
-commonly manifest as jet lag or shift work disorder
42
Jet lag
-non- pharm: napping, timed light exposure
-Melatonin, ramelteon, short-acting benzos
-take drug at target destination bedtime to reduce jet lag and shorten sleep latency
43
Shift Work Disorder
-difficulty with sleep or wakefulness at times that are imposed by shifts running counter to the light-dark cycle
-non pharm: sleep scheduling, sleep hygiene, naps before or during shifts, exposure. to bright light at night and darkness during the day
Pharm options: melatonin, ramelteon, short acting benzos or suvorexant, modafinil and armodafinil to improve wakefulness
44
Parasomnias
-abnormal behavior or physiological events that occur during sleep
-sleep walking, terrors and talking occur during NREM sleep
-may br due to taking a Z-drug with alcohol or antidepressants
Treatment:
-protect the individual from harm, benzos, SSRIs, or TCA, reduce stress, anxiety, and sleep deprivation to reduce nightmares
45
Pharmacotherpy for RLS
-intermittent symptoms:
-carbidopa-levodopa
-BZDRA (clonazepam)
-low dose opioid
chronic and persistent symptoms: pregabalin, gabapentin, immediate-release pramipeole, ropinirole, rotigotine
46
Migraine
-positive visual symptoms
-gradual onset/evolution
-sequential progression
-repetitive attacks of identical
-flurry of attacks midlife
-duration < 60 mins
-headache follows ~50%
47
TIA
-visual loss
-abrupt
-simultaneous occurence
-duration < 15 mins
-headache uncommon
48
NSAIDs used for Headache
-Diclofenac potassium oral solution (cambia)
--> indicated for the acute treatment of migraine attacks with or without aura in adults 18+
--> mix single packet contents with 1-2 ounces of water to administration
-Celecoxib oral solutions (Elyxyb)
--> indicated for the acute treatment of migranes with or without aura in adults
49
Butalbital/APAP/caffeine (Rioricet, Bac, Segic, Zebutal)
*reserve for pts w/o alt treatment options
-BBW for hepatotoxicity (APAP)
-indiated fro tension-type headache, but also used in migraine
AEs: CNS depression, stomach upset
50
Butalbital/ASA/Caffeine (Fiorinal)
-indicated for tension-type headache, but also used in migraine
-AEs: CND depression, stomach upset
51
Triptans in use of headache tx
-acute tx of moderate to severe migraines
-administer early in the course of a migraine attack to improve response
AEs: flushing, chest pain, aplpitations, dizziness, fatigue, xerostomia syndrome
**limit use to < 10 days/month
CI: hemiplegic migraine or migraine with brainstem aura, ischemic heart disease, wolff-parkinsin-white syndrome, stroke.TIA, peripheral vascular disease, ischemic bowel disease, uncontrolled HTN, within 24 hrs of an ergotamine or MAOIs (rizatriptan, sumatriptan, zolmitriptan only)
52
Triptan meds used in moderate to severe migraines
-Almotriptain: better tolerated than suma, penetrates the BBB easier, contains a sulfa group
-Eletriptan: most lipophilic triptan
-Frovatriptan: longest 1/2 life
-Naratriptan: slower onset, fewer headache recurrence than suma
-Rizatriptan: dose reduction with propranolol
-Sumatriptan: PO, intranasal, SQ, lowest oral bio.
-Zolmitriptan: PO, ODT, instranasal
53
Lasmiditan (Reyvow)
-serotonin 5-HT receptor agonists
-indication: acute tx of migraine w/ or w/o aura
*50-200 mg max 1 dose/day! repeat doses have not demonstrated efficacy
*must wait at least 8 hours before driving
AEs: CNS DEPRESSION, serotonin syndrome, dec HR, inc BP, palpitations, dizziness, N/V
54
Rimegepant (Nurtec)
-PO ODT
-indications: acute AND prevention tx of migraines
(acute: 75mg/day, prevent: 75 mg EOD)
-onset of action < 2 hours
AEs: abdominal pain, dyspepsie, nausea
55
Ubrogepant (Ubrelvy)
-ACUTE tx of migraine with or w/o aura
-dose: 50-100mg once can repeat dose after 2 hrs, MDD 200mg
-CI with strong cyp3a4 inhibitors (keto) - admin with high fat meal delays Tmax by 2 hours
-AEs: nausea, drowsiness, xerostomia
56
Anti-migraine Ergots
-binds with high affinity to certain serotonin, noradrenaline, and dopamine receptors
BBW: CI with potent CYP3A4 inhibitors (protease inhib. macolides, azoles)
**do not use in prego/breastfeeding, within 24 hrs of a triptan, coronary artery disease, uncontrolled HTN
Serious AEs: cardiac valvular fibrosis, ergotism, SS
57
Ergotamine (Ergomar)
-acute tx of moderate to severe migraine
-not rec in older adults
AEs: N/V, ECG changes, HTN, ischemia, vasospasm, numbness, paresthesia, gangrene
-increaction with grapefruit = inc concentations
-may worsen N/V
-d/c may result in in withdrawal/rebound headache
58
Dihydroergotamine *DHE: migranal, trudhesa)
-injection: Acute tx of cluster headaches
-injection & nasal spray: acute tx of migraine w or w/o aura
CIs: ischemic heart disease, hx of MI, angina, following vascular surgary
-do not use within 24 hrs of triptans
-admin 1st dose in facility & obtain ECG immediately following 1st dose in pts with CAD risk factors
59
Severe migraine tx in ED
-IV/IM dexamethasone (reduces early headache occ)
-SQ sumatriptan (quick onset)
-IV prochlorperazine + diphenhydramine
-IV metoclopramide + diphenhydramine
-IV chlorpromazine + diphenhydramine
-IV DHE + antiemetic (metoclopramide)
-IV valproate
-IV/IM ketorolac
-IV magnesium
60
Migraine preventive tx
-if attacks interfere with ots daily routine
-frequent attackes (6+day/month, 4+ days/month (mod), 3+ days/month (sev))
-CI, failure or overuse of acute tx
-AEs with acute tx
-pt preference
61
Topiramate
-indicated for prevention of migraine headache in pts > 12 y/o
AEs: cognitive dysfunction, CNS effects, nephrolithiasis, metobolic acidosis, angle-closure glaucoma, hyperthermia, suicidal ideas, weight loss
-counsel on imporance of hydration
-avoid in pregos
62
Valproic Acid
BBW: hepatotoxicity, pts with mitochondrial disease, fetal risk, pancreatitis
-indicated for headache prevention
-AEs: CNS effects, hematologic effects, hepatotoxicity, encephalopathy, TEN/SJS, DRESS, pancreatitis, suicidal ideation
**dont use for prevention of migraine in pregos or women of CBA not on BC
63
Beta blockers used in migraine prevention
-propranolol & timolol
64
TCAS in migraine prevention
-amitriptyline, nortriptyline
-BBW: suicidality
--> lower initial doses for MP than for MMD
-AEs: anticholinergic effects, CNS depression, cardiac conduction abnormalities, hypotension, serotonin syndrome
65
Atogepant (Qulipta)
-preventive tx for episodic migraines
-dose: 10, 30, or 60 mg ONCE daily
AEs: constipation, nausea, drowsiness, fatigue, weight loss
66
Eptinezumab (Vyepti)
-CGRP ligand
-IV q 3 months
AEs: infusion reactionnasopharyngitis, nausea
67
Erenumal (Aimovig)
-CGRP receptor
-SQ monthly
AEs: constipation
68
Fremanezumab (Ajovy)
-CGRP ligand
-SQ q month or q 3 months
69
Galcanezumab (Emgality)
-CGRP ligand
1- prevention of cluster headache during cluster episodes in adults
2- prevention of migraine in adults
-SQ q month
70
Greater occipital nerve block
-lidocaine/bupivacaine/methylprednisolone
**anesthetic nerve blocks are fine in pregos NOT corticosteroids tho
71
PO Magnesium
*mainly used in women of CBA and in older adults
-migraine prophylaxis, especially in migraine with aura (good for menstrual migraine)
-magnesium oxide 400 mg PO BID
AEs: diarrhea, N/V
72
Vitamin B2 (Riboflavin)
-give to menstruating women
-migraine prophylaxis
73
Feverfew
-migraine prophylaxis
-AVOID use in pregos = may cause uterine contractions & abortions
AEs: GI upset
-50-105 mg daily for up to 4 months
74
Butterbur (Petasites)
-migraine prophylaxis
-avoid products that are not labeled as PA-free
-AEs: GI, drowsiness, fatigue, pruritis, rash, hepatotoxicity
75
OnabotulinumtoxinA (botox)
-indicated for prevention of chronic migraine headaches
-admin every 12 weeks by provider
-BBW: spread of toxin effect: muscle weakness, diplopia, ptosis, dysphagia, breathing issues
AEs: injection site pain, neck pain, myalgia, facial paresis
76
Menstrual Migraine Pharmacotherapy
1- frovatriptain: 2.5 mg once- BID 2 days prior; continue for 6 days total
2- Naratriptan: 1 mg po BID 2-3 days prior; continue for 5-6 days
3- zolmitriptan: 2.5 mg PO bid -tid 2 days before; continue for 5-7 days
-PO magnesium etc
***avoid estrogen containing contraceptives in migraine with aura pts
77
Consiseration for contraceptives
**estrogen increases risk of ischemic stroke and should be avoided in women with migraine with aura who already have an increased stroke risk
78
acute migraine tx for pts with cardio/cerebrovascular disease
-gepants (aimvig, ajovy, emgality, vyepti)
-lasmiditan
79
acute migraine tx for pregos
-FIRST line = APAP
-avoid NSAIDs in 3rd trimester
80
Preventative tx for tension type headache
-antidepressants: TCAs, mirtazapine, venlafaxine
-anticonvulsants: gabapentin, topiramate
-trigger point injections
81
Acute cluster headache tx
-oxygen
-SQ (pref) or intranasal sumatriptan
-intranasal zolmitriptan
82
Preventive tx of cluster headaches
-VERAPAMIL (gold standard)
-glucocorticoids
-galcanzumab
-lithium
-topiramate
-greater occipital nerve block
83
tx of hemicrania continua
#1= Indomethacin
alts: onabotulinumtoxinA, occipital nerve stimulation, occipital nerve stimulation, vagus nerve stimulation, peripheral nerve block
84
Pseudotumor cerebri treatment
-withdraw offending agent
-weight loss
-acetazolamide
-topiramate
-furosemide
85
**brain tumor headache red flags**
-acuute, new, usually severe headache or headache that has changed previous patterns
-new headache onset in an adult, esp over 50 y/o
-headache in older adults or in children
-headache on exertion, onset at night, or onset at early am
-headache that is progressive in nature
-headache associated with fever or other systemic symptoms
-headache with meningismus
-headache with new neurologic signs
-precipitation of head pain with the Valsalva meneuver (coughing, sneezing or bending over)
86
Reversible Cerebral Vasoconstriction Syndrome
-reversible multifocal narrowing of the cerebral arteries = thunderclap headaches
-most common in females aged 20-50
-meds associated with RCVS: SSRIs, triptans, ergots, cyclophosphamide, tacrolimus, nasal decongestants, illegal drugs
87
Subarachnoid Hemorrhage
-sudden or thunderclap onset of headache --> reaches max intensity in seconds
-N/V, photophobia, neck stiffness, focal neurologic deficits, brief loss of consciousness
*life-threatening emergency*
88
medication overuse headaches
-increased excitability on neurons in the cerebral cortex + trigeminal system
--> anti-migraine ergots, triptans, opioids > 10 days/month
-->non-opioids > 15 days/month
-->butalbitals > 5 days/month
89
Headache red flags: SSNOOP
-systemic s/s (fever, myalgias, weight loss
-systemic disease (malignancy, acquired immune deficiency
-neurologic s/s
-onset sudden (thunderclap)
-onset after age 40 y/o
-pattern change
90
TX for acute exacerbation: acute severe attack (MS)
1) methylprednisone: 1 gram IV infusion per day x 3-5 days the PO prednisone taper 60mg qd x7, 60mg qod x7d, 40mg qod xy, then 20mg qod x7 then stop
-H2 blocker/PPI for ulcer prophylaxis
-monitor BG and watch for infection
2) corticotropin Acthar gel: IM or SQ: 80-120 units/day for 2-3 weeks
91
Interferon beta use in MS
-indicated for relapsing forms: clinically isolated syndrome, RRMS and active SPMS
92
Interferon beta-1a (& 1b) drugs used in MS
1- Avonex: IM given weekly
2- Rebif: SQ given 3x week
3- Plegridy: SQ give q 14d
*do not use in pregnancy*
Interferon beta-1b: Betaseron, Extavia: SQ given every other day
93
Interferon beta: side effects
-FLU LIKE SYMPTOMS (premedicate)
-injection site reactions
-depression
-myalgia
-asthenia
-asthralgia
-diaphoresis
-myasthenia
-abdominal pain
94
Glatiramer acetate (copaxone, glatopa)
-SQ injection given once daily
--> one of the safest drugs to give a women who is going to become pregnant
indication: relapsing forms including clinically isolated syndrome, RRMS and active SPMS
SEs: INJECTION SITE REACTION, flushing, vasodilation, chest pain/tightness, asthenia, N/V, pain, arthralgia, anxiety, palpitations, dyspnea, constriction of the throat
95
Natalizumab (Tysabri)
-humanized monoclonal antibody
-IV infusion given every 4 weeks
*dont use in the pregos*
-indications: relapsing forms including clinically isolated syndrome, RRMS, and active SPMS
**PML risk: 3 factors can increase ones chance of developing: testing + for antibodies to JCV, prior use of certain immunosupprants, using natalizumab for more than 2 yrs
SEs: infusion reactions, respiratory tract infection, UTIs, depression, headache, fatigue, diarrhea, cholelithiasis, arthralgia & PML
96
Alemtuzumab (Lemtrada)
indicated: relapsing forms of MS, generally reserved for inadequate response to 2 or more meds (evaluated for RRMS and SPMS)
**pre-medicate with corticosteroids and administer antiviral prophylaxis
**avoid use in pregos
SEs: DEVELOPMENT OF AUTOIMMUNE THYROID DISORDERS, rash, headache, pyrexia, fatigue, puritis, N/V, diarrhea, dizziness, chills, insomnia, chest discomfort, musculoskeletal pain, dyspepsia, flushing, UTIm URI, fungal infections
97
Alemutuzumab BBWs & monitoring
1) causing of serious/sometimes fatal autoimmune conditions (immune thrombocytopenia and anti-glomerular basement membrane disease)
2) infusion reactions
3) increase risk of malignancies (thyroid cancer, melanoma & lymphoproliferative disorders)
Monitor: CBC, urinalysis, TSH, observe for 2 hours after infusion, ECG, no live vaccines
98
Ocrelizumab (Ocrevus)
-huminized monoclonal antibody
-significantly reduces release rates, disability progression and disease activity on MRI in pts with RRMS AND SPMS
Indications: PPMS, relassing forms of MS, including CIS, RRMS, and active SPMS
99
Ocrelizumab SEs
-infusion reaction --> pre-medicate pts with steroids (methylprednisolone 100mg IV 30 mins prior), antipyretics (APAP) & antihistamines (diphenhydramine), UTI, URI, headache, nausea
CIs: hep B reinfectation, herpes infection, malignancy, PML
100
Ofatunumab (Kesimpta)
-new drug that pts can administer on their own
-administer all live vaccines at least 4 weeks prior
AEs: decrease in immunoglobulin levels may occur with use, inc risk of URI, PML
-females of reproductive age should use effective contraception during therapy and for 6 months
101
Mitoxantrone (Novantrone)
MOA: intercalates with DNA strands causing breaks and inhibits DNA repair
-IV q 3 months
NO PREGOS
-indication: SPMS, PRMS or worsening of RRMS to reduce neurologic disability and/or frequency of clinical relapse
Limitation of use: not indicated for the tx of PPMS, RESERVE use for rapidly-advancing refractory MS
SEs: cardiotoxicity, bone marrow suppression, oral ulcerations, N/V, alopecia, headache, fatigue, hepatic dysfunction
102
Mavenclad
-treatment of relapsing forms of multiple sclerosis and active SPMS in adults who have had inadequate response or are intolerant to other therapies for MS
-following 2 years of tx, do not administer oral cladribine during the next 2 years
-wash hands and separate admin of this with other meds --> single gloving for admin of intact tablets
103
Mavenclad BBW
-malignancies
-teratogenicity
-CI in pregos (stop tabs if the pt becomes pregnant)
-bone marrow suppression, infection, PML, vaccines, graft-versus-host, hepatotoxicity, cardiotoxicity
Monitor: CBC, HIV, tb and hep B, varicella-zoster virus, prego test, liver function tests, MRI prior to first tx course, cancer screening, s/s of acute infection
104
Fingolimad (Gilenya)
Indication: relapsing froms of MS, inclusing CIS, RRMS, and active SPMS in pts > 10 y/o
-see reduced lymphocyte count (7-% reduction at .5mg SS), heart rate decrease on day 1
-first dose monitoring: ECG needed before initiating, monitor hourly for 6 hrs post 1st dose for bradycardia, repeat 1st dose monitoring it pfts misses 1 day in first 2 weeks, 7 days in 3rd and 4th weeks or 14 days after 1 month
--> higher risk: prolonged QTc,
--> CI in: recent MI, unstable angina, stroke, transient attack,
SEs: headache, leukopenia, URTI, macular edema, inc in BP, LFT elevation, abdominal pain, diarrhea
105
Mayzent/Siponimod
-tx of relapsing forms of MS, including CIS, RRMS, and active SPMS
-store unopened containers in a refrigerator
-CYP2Cp *1/*1, *1/*2, or *2/*2: 2mg QD
-CYP2c9 *1/*3 or *2/*3: 1 mg qd
CI with *3/*3
-only high risk pts need to be monitored after 1st dose admin
Warnings: infections, immunizations, PML, macular edema, bradycardia, atrioventricular, QT prolongation, cardiovascular disease, respiratory effects, hepatic effects, HTN, neurotoxicity, malignancy,
*do not use in the pregos
106
Mayzent/Siponimod monitoring
monitor: CBC, hepatic, ECG, S/S of infection, monitor for sus skin lesions
-severe inc in disability following discontinuation of therapy
-additonal monotoring for pts with sinus bradycardia --> first dose 6 hr monitoring, pts may also require overnight monitoring during tx if they have prolonged QTc
107
Zeposia/Ozonimod
-CI in MI, unstable angina, stroke, transient ishemic attack, HF
warnings: AV block, bradycardia, hepatoxicity, HTN, infections, lymphomas, macular edema, neurotoxicity , PML, respiratory effects, cardio,
--> evaluate prego status prior to use in females of repro age (elimination takes ~3 months)
AEs: infection, URTI, cardio, GI, UTI, hepatic
108
Zeposia/Ozonimod monitoring
-concurrent ingestion of foods and bevs with high amount of tyramine (can cause hypertensive crisis)
-monitor: CBC, ECG, ophthalmologic exams
109
teriflunomide (Aubagio)
*selectively produces a cytostatic effect on proliferating T and B lymphocytes in the periphery
*reduced B-lymphocyte proliferation
-indication: relapsing forms of multiple sclerosis
SEs: headache, nasopharyngitis, URTI, alopecia, sensory disturbances, nausea, paresthesias, insomnia, fatigue, UTI, increases in LFTs, back pain, limb pain, diarrhea, arthralgia
Common adverse effects: diarrhea, elevated ALT, nausea, influenza, neuropathy
110
Teriflunomide (Augbagio) monitoring & BBW
-may decrease WBC- CBC within 6 months before starting
-liver function within 6 months and q month for at least 6 months after
-screen for latent TB
BBW: hepatotoxicity, teratogenicity (detected in semen, decreased sperm count in men)
DDI: dose of rosuvastatin should not exceed 10 mg in pts, may decrease INR in pts taking warfarin
111
how do you accelerate elimination of Teriflunomide (Aubagio)?
-cholestyramine 8 or 4 g q 8h x 11d or
-50 g activated charcoal q 12 hrs x 11 d
112
Dimethyl fumarate (Tecfidera)
-approved as oral therapy for relapsing forms of MS including CIS, RRMS, and active SPMS
SEs: GI SYMPTPOMS!, flushing, transient increases in LFTs, transient esoinophelia, lymphopenia, PML
113
Diroximel Fumerate (Vulmerity)
-causes less GI adverse effects
-may administer aspirin 30 mins prior to diroximel to reduce the severity of flushing
114
Monomethyl fumerate (Bafiertam)
-leads to less GI effects
-admin of non-enteric coated aspirin up to 325mg 30 mins prior to this may reduce incidence of flushing
115
How is Spasticity treated?
-baclofen
-dantrolene
-diazepam, clonazapam
-tizanidine
-gabapentin, tigabine, pregablin
-botox
-dalfampridine (only med approved for MS)
(weed)
116
How to treat over active bladder or urinary retention in MS?
-propantheline
-oxybutynin
-desmopressin acetate
-cathetherization
-imipramine
-prazosin
-botox
-anticholinergics
-miradegron (Myrbetiq)
117
How to treat sensory symptoms of MS?
-carbamazepine, oxacarbazapine
-phenytoin
-TCAs
-gabapentin
-lamotrigine
-pregabalin
-duloxetine
118
How to treat fatigue.cognitive issues/emotional issues in MS?
-amantadine
-SSRI/SNRI
-modafanil
-methylphenidate
-dextroamphetamine
119
How is pseudo bulbar affect (PBA) treated in MS?**
(uncontrolled episodes of crying or laughing)
-NEUDEXTA (dextrometorphan HBr and Quinidine Sulfate)
120
What drugs can help with walking in MS?
-Dalfampridine (Ampyra)
-CI in pts with moderate or severe renal impairment, hx of seizure
AEs: asthenia, balance disorder, dizziness, HA, insomnia, paresthesia, nsaopharygitis, pharyngloaryneal pain, constipation, dyspepsia, nausea, back pain, UTI
121
What is cannabinoids used in MS?
-may be effective for spaasticity, MS related pain, painful spasm, and bladder voiding
122
2 causes of hemorrhagic stroke
1) subarachnoid hemorrhage: typically an aneurysm in large vessels that transverses the surface of the brain in the subarachnoid space --> that vessel bursts and there is bleeding in that space which produces pressure down into the brain = occlusion = stroke
2) Intracerebral hemorrhage: bleeding right into the brain = blood toxicity = VERY neurotoxic!
123
2 causes of Ischemic Stroke
1) embolism: clot that travels from site where it was formed (somewhere else in the body)
2) Thrombus: blood clot that forms in a vessel
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transient Ischemic Stroke (TIA)
-cerebral ischemic event lasting less than 24 hrs (typically only mins w/o apparent permanent neurologic deficit) = no permanent damage to the brain
125
Completed stroke
-cerebral ischemic acute event w/ deficits that persists = if interruption of blood flow to that area is longer than a few mins
126
Hemispheric Infract
EXTREME!
-completely paralyzed on one side, cant speak or understand
127
Lacunar Infarct
-small stroke, no symptoms really
-deep in the subcortical tissue: large infarcts but symptoms tend to be relatively minor
128
microvascular ischemic White Matter Lesions
-least extreme
-occlusions of the tiniest of capillaries, very common and often they are asymptomatic
129
Middle Cerebral Artery Infarct
-wheel chair bound, cannot speak, heavy paresis on one side of his face, a chronic diploma (has to wear an eyepatch) no bladder or bowel control
= complete devastating wipe out stroke
130
Treatable risk factors for stroke
-HTN
-hypercholesterolemia
-heart disease
-DM
-cig smoking
-excessive alcohol intake
-physical inactivity
-obesity
-carotid bruit
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UNtreatable risk factors for stroke
-age
-sex
-race
-prior stroke
-heredity
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Stroke Pathophysiology (thrombus formation)
1- asymptomatic atherosclerotic plaque
2- platelet deposition
3- occlusive thrombus formation
4- plaque fissure --> red thrombus --> embolism
a) primary hemostasis - platelet plug
b) coagulation --> fibrin clot --> thrombus
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Stroke Pathophysiology (Cariogenic Embolus)
-blood stasis --> thrombus --> ejected to brain
134
Clinical Presentation of Stroke/TIA (Carotid territory)
-unilateral weakness
-unilateral sensory symptoms
-aphasia- difficulty understanding speech, speaking or both
-monocular visual loss
-transient global amnesia
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Clinical Presentation of Stroke/TIA (Vertebrobasilar Territory)
(harder to attribute to stroke due to bilateral nature)
-bilateral weakness, sensory, and/or visual complaints
-diplopia, vertigo, ataxia w/o weakness, dysphagia
--> very rapid onset of these symptoms
136
Primary Prevention of stroke care (modifiable and non modifiable factors)
-Modifiable: HTN, hyperlipidemina, smoking, DM, A fib, CAD, obesity, post- men BC use (HUGE stroke risk)
-non-modifiable: age > 55, race (black, hispanic), male gender, fam or personal HX
137
How do you treat a small vessel lacunar, large vessel embolic or a large vessel thrombotic?
antiplatelet therapy
138
How do you treat a cardioembolic event?
warfarin or other oral anticoagulants
139
MOA of Ticlopidine, Clopidogrel & prasugrel in antiplatelets?
IRREVERSIBLE
-blocks ADP receptors = inhibition of plate aggregation and activation
140
MOA of aspirin on antiplateles?
-GOLD STANDARD
-irreversible, inhibits cyclooxyrgenase and thromboxane
-duration of effect is determined by platelet turnover rate (10-14 days)
141
MOA of Dipyridamole in antiplatelet?
*only anti platelet that is REVERSIBLE --> as drug concentration falls, platelet aggregation increases
--> increases plasma adenosine & inhibits platelet phosphodiesterase
142
what dose of aspirin is best?
-older women + pts with diabetic gasteroparesis have very bad aspirin absorption --> use the enteric coated
-the younger you are & the heavier you are = inc the chances that you need a larger dose (325 mg)
--> in acute emergency give 325 mg!!
143
Aggrenox (ASA + Dipridomole ER)
-guaranteed to produce headache in any pt with a hx of headache, GI discomfort, DO NOT use in any pt with GI issues or chronic bowel things
144
what warrants dual anti-platelet therapy?
- coronaery artery stents and new cerebral ischemia
-cerebral ischemia within 90 days
*a fib not able to take coumadin
145
Approach to ASA resistance
-assume compliance: urinary salicylates
-remove drugs that compromise ASA effects: NSAIDs other than celebrex, some herbal supps
-change from EC to chewable ASA (81 mg) or alka seltzer (for 325 mg) --> particularly in older women
-change ASA dose where appropriate
146
Approach to Plavix resistance
-minimize use of other drugs that inhibit CYP3A4 and CYP2C19
-substitite drugs that have lessor effect on these P450 enzymes
-add medications that can induce CPY enzyme activity
147
common medications that influence CYP 3A4 or CYP2C19
-statins other that rosuvastatin
-calcium channel blockers (do not change if they are using it for rate control)
-ambien, lunesta (sonata least likely)
-glyburide (not glipizide or metfromin)
-enablex, ditropan (not detrol or sancturea)
-PPIs --> get rid of them
148
What do you do if the pt is truly resistant to both aspirin and clopidogrel?
1) ticagrelor
2) max ASA dose 100 mg daily with tricagrelor
-Prasugrel
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Herman is a 55 y/o who experienced an episode of sudden onset paresthesia and paresis of his left upper extremity lasting 5 mins. Imaging studies of his brain at the time failed to report any acute ischemic infractions. He was discharged with 81 mg aspirin daily. This occurred in July 2020. He is now being scheduled for lumbar spine surgery for a L5 S1 radiculopathy. You are asked how long after stopping his aspirin will he have normal platelet function and be able to have his surgery?
A: The half-life of aspirin is about 3 hours, so as long as he has been off of aspirin for 15 hours he can have surgery
B: Because of his history of a middle cerebral artery stroke, his aspirin should not be stopped, he is not a surgical candidate
C: Platelet turn over time is approximately 10 – 14 days, so he needs to be off of aspirin for 7-10 days before surgery
D: After surgery aspirin should be restarted for stroke/TIA prophylaxis and Herman should use ibuprofen 400 mg BID for pain
E: After surgery there is no need to restart aspirin because imaging studies of his brain did not report any infarction
C: platelet turnover time is ~10-14 days, so he needs to be off of aspirin for 7-10 days before surgery
150
BDG is a 60 year old male who weighs 350 lbs. that experienced an episode of abrupt onset dystaxia, nausea, diplopia, and upper right extremity paresthesias. He sought medical care and imaging studies of his brain revealed a dissection or thrombosis of the left vertebral artery and infarction in the left lateral medulla. His symptoms slowly resolved leaving him with only a mild dystaxia. He also takes omeprazole for GERD, amlodipine and hydrochlorothiazide for essential hypertension, and atorvastatin for dyslipidemia. He has a history of migraine and a family history for migraine. Based on both outcomes data as well as the specific clinical circumstances of this patient which would be the best for long-term secondary stroke prophylaxis?
A: Aspirin 325 mg daily
B: Plavix 75 mg daily
C: Aggrenox twice daily
D: Ticlopidine
E: aspirin 81 mg
A: aspirin 325 mg (cause he is young and obese- needs larger dose)
--> has headaches so cant use Aggrenox,
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EF is a 45-year-old obese (240 lb) male who presents to your ED 2.5 hours after the abrupt onset of right leg weakness and facial droop. These symptoms persist.
a DVT 4 years ago. He is a good historian and states he never misses a dose of his medication so he is unsure why this is happening. Current medications: Omeprazole 20 mg daily Rivaroxaban 20 mg daily Aspirin 325 mg daily Plavix 75 mg daily Multiple vitamins once daily Vital signs: BP: 170/90 HR: 82 Laboratory values: INR: 1.3 Platelets: 280,000 The team wants to move forward and administer IV tPA before he is outside of the time window. What do you tell them?
A: Administer 9.8 mg of alteplase IV as a bolus dose over 1 minute followed by 88.2 mg of alteplase over 1 hour
B: Administer 9 mg of alteplase IV as a bolus dose over 1 minute followed by 81 mg of alteplase over 1 hour
C: He is already outside of the time window
D: He is not an IV tPA candidate
E: He should be reassessed in 15 minutes to determine if the benefits of IV tPA outweigh the risks
D: he is not a IV tPA candidate
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GH is a 70-year-old male who presented to your hospital and received IV tPA for aphasia and left sided weakness. During the infusion, his blood pressure increases from 160/95 to 205/115. What is the best course of action for GH?
A: Give labetalol 10 mg IV to lower blood pressure below 180 mmHg systolic
B: Give labetalol 20 mg IV to lower blood pressure below 160 mmHg systolic
C: Stop the infusion and obtain a CT scan of the brain
D: Give his home oral antihypertensives to lower blood pressure slowly and prevent further ischemia
E: Begin a nicardipine 15 mg/hr continuous infusion to keep blood pressure below 160 mmHg systolic
A; give leaetalol 10 mg IV to lower BP below 180 mmhg
C: stop the infusion and obtain a CT scan of the brain
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Which of the following are risk factors for bleeding with IV tPA administration?
A: Large stroke with an NIH > 16
B: Blood pressure greater than 190 mmHg systolic
C: Evidence of stroke or mass effect on initial CT scan
D: Administration of aspirin 325 mg 36 hours after onset of symptoms
E: Well-controlled diabetes
B: blood pressure greater than 190 mmHg systolic
C: evidence of stroke or mass effect on initial CT scan
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Richard is an 81 year old man who was admitted to hospital in September for sudden onset difficulties with gait, balance, double vision, speech difficulties and nausea. Imaging studies of
had been taking aspirin 81 mg daily prior to this stroke. He has some residual speech and balance difficulties. He was discharged on aspirin 325 mg daily. His current medications include : Aspirin 325 mg daily Atorvastatin 80 mg at bedtime piroxicam 10 mg three times daily lisinopril 20 mg daily hydrochlorthiazide 12.5 mg daily. He is in for a refill of all of his medications. Which would be your single best course of action
A: Refill his medications and reinforce that should he have a recurrence symptoms like those in September he needs to call 911
B: Contact his physician because the atorvastatin dose should be no more than 40 mg daily in patients over 55 years old
C: Contact his physician because hydrochlorthiazide can cause dehydration which will increase the risk of recurrent stroke
D: Contact his physcian because piroxicam will severely compromise the antiplatelet effects of aspirin
E: Contact his physcian and ask that he be treated with apixaban rather than aspirin because he had a pontine stroke
D: contact his physician bc piroxicam will severely compromise the anti platelet effects of aspirin
155
Ben is a 60-year-old male with SPMS. He is seen with his wife for a routine follow-up. His wife mentions that he now has uncontrollable episodes of laughing and crying. His neurologist is Pseudobulbar Affect (PBA). Which medication is approved or PBA?
A: Dalframpridine / Ampyra
B: Mirabegron / Myrbetriq
C: Dextromethorphan and Quinidine / Neudexta
D: Modafanil / Provigil
C: dextromethorphan and Quinidine/ Neudexta
156
Annie is a 50 y/o woman with RRMS who has had MS for many years. She was initially treated with Glatiramir acetate 20 mg SQ QD, but over the years has grown tired of injecting herself. Her PMH is significant for a myocardial infarction 5 months ago. She also has very thin hair that she is self-conscious about and does not want anything that will cause thinning hair. She travels frequently for work and would like to try an oral medication that she can self-
administer. Which of the following medications do you recommend?
A: Dimethyl furmarate / Tecfidera
B: Terifunimide / Aubagio
C: Ozonimod / Zeposia
D: Sipoinmod / Mayzent
A: Dimethyl Fumarate/ Tecfidera
--> Aubagio: causes hair loss
--> Ozonimod: CI in MI
--> mayzent: need to monitor
157
Mike has relapsing remitting MS. He has heard that medical Cannabis is permitted in NYS. He wants to know if it would help with any of his symptoms. According to some shit, for which symptom is there the strongest evidence of support for oral cannabid extracts?
A: cognitive impairment
B: Fatigue
C: Spasticity
D: Bladder complaints
C: Spasticity
158
Mary has been diagnosed with Primary Progressive Multiple Sclerosis. She has had steady disease progression without clear-cut relapses. Which medication is approved, but has shown the best efficacy for PPMS?
A: Glatiramir Acetate / Copaxone
B: Ocrelizumab / Ocrevus
C: Fingolimod / Gilenya
D: Dimethyl fumarate / Tecfidera
B: Ocrelizumab/Ocrevus
159
Marissa is a 34 year old diagnosed with Multiple Sclerosis. She is currently experiencing a MS relapse consisting of a pain and tightness sensation around her midsection that
over 48 hours and has also had another relapse in the past. She has an older non-enhancing lesion on her MRI as well as a new Gd+ enhancing lesion. She has also had a spinal tap consistent with MS. Marissa is currently married and has just started trying to conceive. Which of the following medications, if any, is most appropriate for a disease modifying therapy?
A: Siponimod / Mayzent
B: Teriflunomide / Aubagio
C: Cladribine / Mavenclad
D: None of these above medications are appropriate in a patient actively trying to conceive.
D: none of these
160
Marissa is a 34 y/o with MS. She is currently experiencing a MS relapse consisting of a pain and tightness sensation around her midsection she referes to as the "MS hug". She has had this symptom for over 48 hrs and has also had another relapse in the past. She has an older, non-enhancing lesion on her MRI as well as a new Gd+ enhancing lesion. She has also had a spinal tap consistent with MS. Which of the following medications is most appropriate for treating her current relapse?
A: Methylprednisolone 1000 mg IV x 3-5 days
B: Natalizumab 300 mg IV q month
C: Mitoxantrone 12mg/m2 q 3 mo
D: Ocrelizumab 600 mg q 6 mo
A: Methylprednisolone 1000mg IV x 3-5 days
--> tx for acute exacertabtions!!
161
what drug is the safest to use in pregos with MS?
Glamtiramer acetate
162
A 25 year-old female, has had multiple trips to the ER for severe headaches. These headaches start all of
MRI of the brain and lumbar puncture at first visit were unremarkable. There was no evidence of any subarachnoid hemorrhage or bleeding in the head. She has a past medical history of typical migraine headaches, however, these are more unilateral, throbbing, associated with nausea, light sensitivity. She was recently diagnosed with major depressive disorder, after episode of binge drinking, and started on Citalopram. She has been self-medicating with marijuana, and noticed that it helps her with sleep as well as her anxiety. She is currently in her menstruation cycle, has been taking newly prescribed hormonal Contraceptive but contains higher dose of Estrogen than her previous combination pill. What is the diagnosis, and what medications and or factors in her clinical history can be a contributing factor to her presenting symptoms? Check all that apply.
A: Thunderclap headache from binge drinking.
B: Thunderclap headache from ruptured aneurysm from marijuana use with SSRI
C: Reversible cerebral vasoconstriction syndrome from marijuana, SSRI, high estrogen dose.
D: Reversible cerebral vasoconstriction syndrome from alcohol and marijuana
E: Reversible vasoconstriction syndrome from SSRI, marijuana
D: reversible cerebral vasoconstriction syndrome from mj and alcohol
E: reversible vasoconstriction syndrome from SSRI, mj
163
A 54-year-old male patient with past medical history of controlled hypertension, diabetes, hyperlipidemia, currently on low-dose Aspirin, experiencing 4-8 migraine headache days per month. He is a nonsmoker, non-obese, and has a non- stressful job working as a school bus driver. He has tried Sumatriptan in the past without significant benefit, but he did have adverse reactions. Which of the following medications below do not have any vascular constriction, and could be a goodd choice for this patient for acute treatment? (Check all that apply).
A: Ubrelvy (ubrogepant)
B: Nurtec (rimegepant)
C: Reyvow (lasmiditan)
D: Aimovig (Erenemuab)
E: Maxalt (rizatriptan)
A: Ubrelvy
B: Nurtec
164
Which of the following patient presentations may be a 'red flag' while evaluating a patient for headache and warrant further work up. (Check all that apply).
A: 19 y. o. Obese female with migraine without aura, positive for smoker.
B: 31 y. o. female with whose headaches are exacerbated with vasalva.
C: 45 y. o. female that experiences numbness and tingling down the left side of her extremeties, with an increase in frequency of headaches.
D: 35 y. o. cluster headache patient with positive neurological signs such as eyelid droop during acute attack. E: 50 y. o. male with right temporal pain, and scalp tenderness.
B: a 32 y/o female whose headaches are exacerbated with vasalva
C: a 45 y/o female that experiences numbness and tingling down the left side of her extremities, with an increase in frequency of headaches
E: a 50 y/o male with right temporal pain and scalp tenderness
165
George is a 50-year-old male with a history of essential hypertension who comes into your pharmacy to refill his metoprolol and HCTZ. He complains of no begin able to get a good nights sleep. He jokes that his wife isn’t sleeping well either. She tells him he is kicking her all night long. For his own benefit, as well as his wife’s, can you recommend an over-the-counter product to help them sleep? Which is your single best course of action?
A: Have him start taking diphenhydramine 50-75 mg at bedtime, a review of his records provides no medical reasons not to, and it will help his sleep. You cannot make recommendations regarding his wife because you do not have her records.
B: Have George and his wife start taking diphenhydramine 50-75 mg at bedtime. It is a safe dose, and there are very few contraindications in 45-50-year-olds
C: Suggest he call his primary care physician
* D: Have him start taking vitamin B and iron supplements. If the symptoms do not improve, refer him to a sleep medicine provider. Warn him not to use over-the-counter sleep aids
E: Call his primary care provider because metoprolol may be aggravating these symptoms
D: have him start taking Vit B and iron supplements. If the symptoms do not improve, refer him to a sleep medicine provider. Warm him not to use over-the-counter sleep aids
166
Patients with obstructive sleep apnea should always take their CPAP machine with them if they are hospitalized because untreated obstructive apnea can: Choose one.
A: cause renal artery perfusion and reduction in glomerular filtration rate
B: increase the likelihood of iatrogenic pneumonia, especially in a hospital
C: decrease the hypercapnic and hypoxic drive to breath when patients are treated with narcotics
D: exacerbate preload and aggravate congestive heart failure
E: none of the listed answer choices are true statements
C: decrease the hypercapnic and hypoxic drive to breath when pts are treated with narcotics
167
A 75-year-old woman comes into your pharmacy asking for something to help her sleep. Despite going to bed at 9:30
She arises each morning feeling unrested. Her social life, while relatively stable during the past year, is disrupted because she is compelled to nap daily between 3 and 4:30 p.m. She is an otherwise well-nourished, hypertensive patient well- controlled with atenolol 50 mg daily. What would you recommend for this patient?
A: Diphenhydramine 25 mg at bedtime along with sleep hygiene counseling
B: Suvorexant 1 mg, no more than 30 mg before bed
C: Evaluation for Obstructive Sleep Apnea
D: Triazolam 0.25 mg at bedtime for 2 weeks along with sleep hygiene counseling
E: Sleep hygiene counseling
E: sleep hygiene counseling
168
45 year old male with a PMH of obesity, hypertension, and sleep apnea (he uses a CPAP) comes into your pharmacy with a prescription for Penicillin G and Lortab. He tells you he recently had a tooth surgery for an impacted, infected wisdom tooth and comes in with prescriptions are for post surgery care. Which of the following two statements are true?
*You should fill both prescriptions because his surgery is real and it’s an infection
* You should check his blood pressure
*You should not fill Lortab
- you should check his blood pressure
-you should NOT fill lortab (opioid that can cause resp depression in pts with sleep apnea)
169
Lawyer question where his wife died and he lost interest in his job and golfing which he previously enjoyed and now he can’t sleep, what is the best choice to manage his insomnia?
-treat depression with sertraline and counsel on good sleep hygiene
170
JP is a 25 year old female of northern European descent presenting with of worsening of a pre existing walking and fatigue. She also has new onset of poor bladder control. Which of the following would be used to treat her acute exacerbation of MS?
Methylprednisolone IV
171
JP is currently on contraception and you are concerned about her becoming pregnant while on MS therapy. Which of the following would be least appropriate (i.e. pregnancy category X) in this patient?
○ mitoxantrone (novantrone) -D
○ glatiramer acetate (copaxone) -B
○ fingolimod (gilenya)-C
○ interferon beta 1 a (avonex) -C
○ teriflunomide (aubagio) {Category X}
-teriflunomide (aubagio) --> BBW is tetragenicity
172
You decide to be cautious and initiate JP on a MS medication that has the least likely possibility of fetal harm in case she does become pregnant. Which of the following poses the LEAST risk of fetal harm?
○ teriflunomide (aubagio)
○ glatiramer acetate (copaxone)
○ mitoxantrone (novantrone)
○ interferon beta 1 a (avonex)
○ fingolimod (gilenya)
Glatiramer acetate
173
JP ultimately has more than 2 relapses and will begin disease modifying treatment for her MS given IV infusion every 4 weeks. Which of the following medications is she now receiving?
Tysabri
174
JP has poor venous access and an acute MS exacerbation- what can you use?
Acthar gel
175
Patient comes to your pharmacy complaining of chills, fever, HA, and flu-like symptoms. She states that she has recently started a new medication for MS but she can’t remember the name of it. She tells you that it is an injection that she takes every other day. Which of the following is she most likely taking?
○ Betaseron
○ Copaxone
○ Tysabri
○ Gilenya
○ Mitoxantrone
Betaseron (interferons cause flu-like symptoms: tecfidera, vulmetry)
176
. TP is a 32 year old female who has questions about her upcoming treatment with fingolimod. Which of the following is NOT an important counseling point?
Requires first dose monitoring of heart rate for at least 6 hours for development of tachycardia (it does require dose monitoring, but to see if the patient develops BRADYCARDIA, not tachycardia)
177
Symptoms of MS include all of the following EXCEPT:
○ Balance issues
○ Dyspnea
○ Muscle Weakness
○ Short term memory loss
○ Sensitivity to heat
Dyspnea
178
Which patient is most appropriate to respond well to ASA 81mg EC for secondary stroke prophylaxis?
○ 66 year old male with hypertension, dyslipidemia, and ED
○ 56 year old with DM and HTN
○ 46 year old with DM, tobacco use, HTN and dyslipidemia
○ 85 year old with severe acid reflux and uses antacids and high doses of PPI
66 y/o male with HTN, dyslipidemia and ED
179
48 year old patient with long term IDDM, dyslipidemia, atrial fibrillation and is experiencing abrupt onset hemiparesis. Recovered with no deficit. Imaging studies of the brain did report. Doppler studied showed carotid. At this point, the best option to prevent recurrence would be?
○ Aspirin 325mg
○ Clopidogrel
○ Coumadin
○ Atorvastatin
○ Dipyridamole IR ATC plus Aspirin 81mg
Coumadin (always use anticoagulant for Afib)
180
76 year old who had a middle cerebral artery infarct on the left side 5 years ago and was previously going to the VA for his Aggrenox but not it is unavailable through the VA anymore. He is taking Atorvastatin 80mg QD and has dysrhythmias which is treated with amlodipine. He also take omeprazole daily. What might be a reasonable substitute for this patient?
○ Aspirin 325 mg
○ Apixaban
○ Prasugrel
○ Clopidogrel
Aspirin 325 mg: ASA working for patient, need to increase dose from whats in Aggrenox because you’re missing the dipyridamole
