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ND Ontario Prescribing Exam > Neurologic Disorders > Flashcards

Neurologic Disorders Flashcards

1
Q

What are the treatment goals in seizure and epilepsy?

A

Appropriately manage the first seizure.
Prevent seizure recurrence.
Prevent or minimize s/e of anti-epileptic drugs
Optimize quality of life

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2
Q

Choose the best definition of epilepsy:
a) one episode of a provoked seizure that was sustained.
b) 2 unprovoked seizures occurring within 24hrs.
c) 2 unprovoked seizures occurring outside of 24hrs.
d) seizure following recreational drug use.

A

c) 2 unprovoked seizures occurring outside of 24hrs.

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3
Q

Of the four types of generalized seizures, which two almost always start in childhood?
a) tonic clonic and absence
b) myoclonic and tonic clonic
c) absence and myoclonic
d) atonic and absence
e) all of the above

A

d) atonic and absence

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4
Q

What is the drug of choice for absence seizures in childhood?
a) valproic acid
b) phenobarbital
c) ethosuximide
d) lamatrogine

A

c) ethosuximide

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5
Q

T/F Many patients do not require anti epileptic drugs after their first seizure.

A

True

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6
Q

T/F Always withhold benzodiazepines in the acute status epilepticus due to respiratory suppression.

A

False

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7
Q

Which of the following statements is TRUE about prescribing principles in anti-epileptic drugs?
a) Titer the first drug choice up quickly to prevent further seizure activity.
b) Add a second drug soon after the first if a moderate dose hasn’t prevented seizures.
c) Titer the first drug up at a fraction of the recommended dose to avoid s/e.
d) Multiple anti-seizure medications tend to work better than single med.

A

c) Titer the first drug up at a fraction of the recommended dose to avoid s/e.

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8
Q
  1. What nutritional supplement should pregnant women medicated with anti-epileptic drugs take?
    a) folic acid
    b) copper
    c) multivitamin
    d) vitamin K
A

a) folic acid

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9
Q

What are common side effects of anti-epileptic drugs?

A

Sedation, fatigue, cognitive impairment, dizziness and ataxia

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10
Q

Name 4 primary drugs for generalized tonic-clonic seizures.

A

Carbamazepine
Lamotrigine
Phenytoin
Valproic acid

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11
Q

Which of the following migraine prophylaxis medications should NOT be prescribed for an asthmatic child?
a) Flunarizine
b) Propranolol
c) Amitriptyline
d) Pizotifen

A

B. All of the above agents are used for migraine prophylaxis in children but, since nonselective beta-blockers can cause bronchospasm, propranolol should be avoided in this patient (page 232, CTC 7th edn)

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12
Q

JM is a 15-year old patient on eletriptan for migraine headaches. Which of the following could safely be given to this patient?
a) Ibuprofen
b) Escitalopram
c) Clarithromycin
d) Ketoconazole
e) Sumatriptan

A

A. This patient could take ibuprofen safely. Escitalopram is an SSRI, and triptans should be used with caution with these agents as well, there are concerns about increased suicidality when using an antidepressant in children. Eletriptan is contraindicated within 72 hours of CYP3A4 inhibitors (clarithromycin and ketoconazole). One triptan should not be taken within 24 hours of another triptan.

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13
Q

When treating neuropathic pain, which of the following is TRUE:
a) First-line agents are amitriptyline, gabapentin and pregabalin
b) Artificial saliva mouth spray cannot be given with amitriptyline if the patient experiences dry mouth
c) Gabapentin has no significant interactions with common over the counter medications like ibuprofen, cough and cold remedies or antacids
d) A stool softener should not be given with opioids and amitriptyline
e) Codeine is not a good choice for treating severe pain

A

A. TCAs (amitriptyline) cause dry mouth due to their anticholinergic effects and artificial saliva is a good option. Both opioids and TCAs cause constipation and, since these agents will be used on a regular basis, a stool softener or other laxative should be given as a preventive measure (page 262 CTC, 7th edn). Amitriptyline is standard therapy for neuropathic pain, but gabapentin and pregabalin are alternative first-line agents. The bioavailability of gabapentin is reduced by OTC antacids; since this agent causes GI upset, concomitant use of these agents should be avoided. Codeine is a poor choice for treatment of severe pain because conversion of codeine to morphine in the liver can be unreliable, leading to adverse effects or poor pain control (page 261 CTC, 7th edn).

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14
Q

Which of the following statements regarding the treatment of neuropathic pain is FALSE?
a) Acetaminophen with codeine (Tylenol #3) is a first line treatment for neuropathic pain
b) If patients are too sedated on amitriptyline, nortriptyline may be better tolerated
c) Some patients may obtain better relief of pain with a combination of a TCA (such as
amitriptyline) and a antiepileptic drug (such as gabapentin)
d) If carbamazepine must be used during pregnancy, folate supplementation (5mg/kg) is
recommended

A

A. Opioid treatment is usually tried as a third line treatment option for people who have significant neuropathic pain refractory to first line agents (Figure 1, page 260 of Therapeutics choices). Nortriptyline is less sedating than amitriptyline and may be a reasonable choice. Combinations therapies such as amitriptyline and gabapentin can have synergistic effects on pain and CBZ is associated with increased risk of neural tube defects (page 262, CTC, 7th edn).

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15
Q

AB, a 35-year old pregnant patient of yours, presents with the Bell’s Palsy symptoms of mild facial weakness of the upper and lower face, ear pain and altered taste which began about 5 days ago and hasn’t worsened since. Which of these statements represents your best response?
a) No treatment is necessary since ~85% of cases resolve without treatment
b) Morphine 10mg q4h prn for the ear pain
c) Acyclovir 400mg 5 times daily for 10 days
d) Prednisone 1mg/kg daily for 5 days, then taper dose for 5 days

A

A. Up to 85% of cases recover spontaneously without treatment. Ibuprofen or acetaminophen with or without codeine may be used for pain in the first day or two, but more potent agents are not usually needed. Acyclovir is seldom given without prednisone and its’ benefit is not established (page 201, CTC, 7th edn). Prednisone would not be used since treatment is unnecessary for mild weakness that is no longer evolving (Figure 1, page 202, CTC, 7th edn).

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16
Q

Which of the following have been shown to be useful in the treatment of restless legs syndrome?
a) Diphenhydramine b) Caffeine
c) Pramipexole
d) Fluoxetine
e) Alcohol

A

C. Pramipexole, a dopamine agonist, is one of the drugs of choice in the treatment of restless legs syndrome. All of the other agents have been shown to contribute to its’ symptoms.

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17
Q

MJ is a 27-year old female whose epilepsy is well-controlled on lamotrigine. She and her husband have decided that they are ready to start a family, so she wants to discuss her plans with you. You talk to her about the need for folic acid to prevent any teratogenic effects from the antiepileptic agent and recommend:
a) A multivitamin
b) Folic acid 0.4mg daily
c) Folic acid 10mcg daily
d) Folic acid 5mg daily

A

D. Women on antiepileptic drugs should receive at least 1mg (up to 5mg) daily starting before conception and during the pregnancy to prevent neural tube defects (bottom of page 306, CTC, 7th edn). All of the other choices would not provide enough folic acid.

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18
Q

When treating fever in children, you have to consider that:
A) Dosing of acetaminophen and ibuprofen should be by age
B) Fever is defined as a rectal temperature consistently over 38oC
C) Acetaminophen is recommended over ibuprofen because it has a larger body of safety data
D) Alcohol is a good sponging agent to reduce fever

A

B. Dosing of acetaminophen and ibuprofen should be by weight due to size fluctuations in all age groups. Alcohol should never be used as a sponging agent because of the risk that it be absorbed through the skin, inhaled or swallowed. Fever is a symptom and is most commonly an adaptive response to an infection. Temperatures taken from the rectum, mouth or tympanic membrane reflect core temperature and fever is defined as a temperature consistently over 38oC taken rectally or the rectal equivalent.

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19
Q

What are the goals of therapy for Restless Leg Syndrome?

A

Improve sleep
Improve symptoms and discomfort
Improve function in pts with daytime s/s
Reduce rebound and augmentation with drug therapy.

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20
Q

T/F Restless Leg Syndrome cases usually have a positive family history.

A

True

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21
Q

Which classes of medications can contribute to Restless Leg Syndrome symptoms?

A

Antidepressants, antipsychotics, dopamine blocking anti-emetics, sedating antihistamines

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22
Q

What nutrient deficiency is associated with Restless Leg Syndrome ?
a) zinc
b) magnesium
c) potassium
d) iron
e) all of the above

A

D

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23
Q

Which one of the following is an appropriate pharmacological choice for Restless Leg Syndrome ?
a) SSRI’s
b) Anti-psychotics
c) Dopamine agonists
d) TCA’s
e) Levothyroxine

A

C

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24
Q

T/F The “rebound” effect of medications refers to the wearing off of effectiveness.

A

True

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25
What role does iron play in the etiology of Restless Leg Syndrome?
25% - 30% of patients with RLS are iron deficient. Risky times include pregnancy and kidney disease. (editor note: I have also seen RLS multiple times in iron overload).
26
What is the order of drug therapy in intermittent Restless Leg Syndrome? a) ibuprofen, benzodiazepines, opiods b) massage ,acetominopen, magnesium c) iron therapy, levodopa, benzos or low potency opiods d) iron therapy, dopamine agonist, GABA derivative
C
27
In daily Restless Leg Syndrome (not intermittent) which is the most appropriate therapy? Levodopa/carbidopa or Levodopa alone?
Levodopa/carbidopa
28
T/F Dopamine agonists are NOT an appropriate choice for long-term therapy of Restless Leg Syndrome
False
29
T/F GABA derivatives are alternatives to dopamine agonists in chronic persistent Restless Leg Syndrome.
True
30
Restless Leg Syndrome in pregnancy may be treated safely with the following: a) iron therapy and clonazepam b) iron therapy and pramipexole c) iron therapy and gabapentin d) iron therapy and folate
D
31
Which of the following substances can contribute to Restless Leg Syndrome? a) caffeine b) nicotine c) alcohol d) all of the above
D
32
Red Flags by condition and drug induced conditions: Epilepsy CARBAMAZEPINE
Narrow Therapeutic Window Therapeutic Drug Monitoring * Use Non-SST Tube!! Drug intx: its levels inc by cimetidine, clarithro/erythro, danazol, diltiazem, felodipine, fluoxamine, fluvoxamine, grapefruit juice, isoniazid, ketconazole, lamotrigine, metronodizole, nefeazodone, phenobarbital, propoxyphene, ritonavir, verapamil and valproate its levels dec by: phenytoin, phenobarb, St John’s wort, theophylline It decreases the levels of- BCP by up to 40%, lamotrigine, phenytoin, theophylline, topiramate, valproate and warfarin
33
Red Flags by condition and drug induced conditions: Epilepsy PHENYTOIN
Narrow therap window; Therapeutic Drug Monitoring * Use Non-SST Tube!! ● Phenytoin (5-20 mcg/ml – therap. range) ○ Known for its highly variable steady-state. Monitored for poorly controlled seizures. *INHIBITS BCP Toxic symptoms – (20, 30, 40mcg/mL: nystagmus, ataxia; disorientation). S/E are acne, coarse face, gum hypertrophy and hirsustism;
34
Red Flags by condition and drug induced conditions: Epilepsy Carbamazepine INTX WITH MACROLIDES
carbamazepine will decrease the level or effect of erythromycin base by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Serious - Use Alternative S/E= rash, dizziness, hyponatraemia, hair thinning
35
Red Flags by condition and drug induced conditions: Epilepsy Sodium Valproate
S/E- tremor, weight gain, hair thinning
36
Red Flags by condition and drug induced conditions: Epilepsy Lamotrigine
Rash-SJS
37
Red Flags by condition and drug induced conditions: Folate Folate deficiency
Methotrexate, phenytoin, trimethoprim- not safe for 1st trimester
38
Red Flags by condition and drug induced conditions: Headaches Headaches
Amitriptyline, Imipramine
 ASA, acetaminophen (frequent use) Benzodiazepines Estrogen Fluoxetine MAOIs Metoclopramide NSAIDS Nitroglycerine Sulphonamides Theophylline Withdrawal of: Benzodiazepines Caffeine Ergotamine Methysergide, ASA, APAP (±codeine) some antihypertensives
39
Red Flags by condition and drug induced conditions: Migraines ERGOT DERIVATIVES
CI in pregnancy, cardiac disorders, HTN, sepsis, PVD, PUD, renal disease, liver disease, or in patients taking potent inhibitors of CYP3A4 (cimetidine, clarithromycin, efavirenz, erythromycin, itra/ketoconazole, ritonavir)
40
Red Flags by condition and drug induced conditions: Migraines TRIPTANS
CI in patients with cardiac disorders, sustained HTN, pregnancy, basilar and hemiplegic migraines ADVERSE EFFECTS- Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat sxs
41
Red Flags by condition and drug induced conditions: Migraines INT TRIPTANS
● Do NOT use with ergotamine-containing products, or with MAOIs ● Caution w/SSRIs or SNRIs (↑ risk of SS) ● Do not use triptans w/in 24hrs of another triptan ● **Various specific interactions depending on drug (See Page 221)
42
Red Flags by condition and drug induced conditions: Migraines ERGOTS INTX WITH MACROLIDES
erythromycin base will increase the level or effect of ergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Serious - Use Alternative
43
Red Flags by condition and drug induced conditions: Parkinsonism Drug induced Parkinsonism
First and second generation antipsychotics, Central dopamine blocking anti-emetics eg metoclopramine prochloroperazine.
44
Red Flags by condition and drug induced conditions: Parkinsonism L Dopa
S/E: nausea, red urine and other bodily fluids, postural hypotension, dyskinesia, on-off and wearing off effects
45
Red Flags by condition and drug induced conditions: Restless Leg Syndrome DRUG INDUCED CAUSES
Antidepressants, Antipsychotics, dopamine blocking anti-emetics, sedating antihistamine (diphenhydramine), Alcohol, Caffeine, Nicotine
46
What drugs are effective for mild to moderate headache pain but their overuse can cause of h/a?
Acetaminophen, ASA, diclofenac, ibuprofen, naproxen (analgesics)
47
How do you use nonopioid analgesics to avoid medication-overuse headaches?
Less than 15 days per month
48
How long do you use opioids and analgesic opioid combination products to avoid medication overuse headaches?
Less than 10 days per month
49
What drug can you use for acute intractable headache and withdrawal from analgesics?
Dihydroergotamine mesylate (DHE)
50
What receptors does DHE interact with?
Dopamine and adrenergic receptors
51
DHE produces dependency. T/F
False
52
Ergot derivatives may produce rebound H/A if used 10 days per month of more. T/F
True
53
Where do triptans work?
Serotonin receptors on extracerebral blood vessels and neurons
54
What is the MOA of triptans?
Prevention of neurogenically sterile inflammatory responses around vessels and vasoconstriction
55
The fastest onset of action of sumatriptan is in this form a. subQ inj b. nasal spray c. tablets d. fast-melt tablets
A
56
The best triptan for severe migrains and acute cluster headache is a. Almotripatan b. Eletriptan c. Frovatriptan d. Naratriptan e. Sumatriptan
E
57
The triptan with the fastest relief is a. Frovatriptan b. Naratriptan c. Rizatriptan d. Sumatriptan
C
58
The triptan with the fewest adverse effects a. Almotripatan b. Eletriptan c. Frovatriptan d. Naratriptan e. Sumatriptan
A (also approved for children 12-18)
59
The triptan with the slowest onset of action a. Almotripatan b. Eletriptan c. Frovatriptan d. Naratriptan e. Sumatriptan
D
60
Which triptan is good for moderately severe migraine attack, low tolerance to s/e or high pain recurrence rate and why?
Naratriptan – has lower h/a recurrence rate and near placebo rates of s/e
61
What are the contraindications for triptans?
Cardiac disorders, sustained hypertension, basilar and hemiplegic migraine
62
What is the maximum number of days in a month one should use triptans?
9 days (less than 10 days)
63
What medication is used for headache with significant nausea and vomiting?
Metoclopramide
64
What medication relieves headache and prevents blindness in temporal arteritis?
Corticosteroids
65
What is the best prophylaxis for tension type headache?
Amitryptiline and nortriptyline (tricyclic analgesics)
66
Which TCA is best tolerated in older patients because of fewer anticholinergic s/e
Nortriptyline
67
Which drug should be avoided in patients with a history of depression and yet they have migraines?
Flunarizine (CCB)
68
MOA of angiotensin receptor blockers in migraine prevention
Direct vasoconstriction, increased sympathetic discharge and/or adrenal medullary catecholamine release
69
MOA of ACE I
Altered sympathetic activity, decreased free radical activity, increased prostacyclin synthesis and reduce degradation of bradykinin, encephalin and substance P
70
The following are s/e and CI of topiramate
CI renal stones, cause increased intraocular pressure, weight loss, CI pregnancy
71
T/F: Headaches are uncommon in children?
F: more than 25% of 13yo have at least weekly headaches
72
T/F: migraine frequency increases with age?
T: 2.4% in 12-14yoa 5% in 15-19yoa
73
What are the specific neurologic symptoms that should be assessed?
Seizures Visual disturbance Balance issues Personality change Weakness
74
4. What are other systems/processes that you should be concerned about with headache? a. Renal b. Cardiac c. Dental d. Infectious disease e. All of the above
E
75
Which of the following is not an examination that should be first line choice in your investigation? a. Neuro exam with cranial nerves b. Muscle tone c. Vitals d. Sinus and dental exam e. Sinus x-ray
e. Sinus x-ray should be done after a phys exam if you suspect sinusitis. Also can do lumbar puncture if suspect infection
76
T/F: it is routine to use diagnostic studies when clinical history and PE is normal because the child may have a serious condition when presenting with chronic headaches
F: diagnostic study is not indicated if no associated risk factors and PE and history are normal
77
What are the non-pharmacologic choices to treat pediatric headaches a. EFT b. Psychological evaluation c. biofeedback d. relaxation therapy e. b,c,d f. a,c,d
E: b,c,d
78
Which of the following can be used to treat acute tension type headache? a. naproxen (NSAID) b. ASA (analgesic) c. Ibuprophen (NSAID) d. acetaminophen (analgesic) e. all of the above
e. all of the above - caution with children and adolescents with fever associated with viral illness!
79
Which of the following is false in regards to Amitryptiline and children’s headaches a. It Is effective at reducing headache frequency and severity b. its use is appropriate for mild/moderate headaches that are frequent c. it can cause weight gain and drowsiness, and anticholinergic sx (dry mouth, constipation) d. it has no disease contraindications
B & D: It is appropriate for disabling and disruptive headaches - It is CI in hypotension or cardiac disease
80
T/F: chronic use of analgesics such as acetaminophen and NSAIDS can induce headaches in the ped population
T: now a recognized cause of headache. Use <15 days per month
81
After exclusion of mass lesion and other headache causes, you should do all of the following except: a. prescribe 5HTP b. encourage sleep and meds early in the course of the headache c. wait before taking medications to see if the headache becomes severe d. discuss migraine triggers
A, C are false
82
T/F: biofeedback and relaxation therapy are ineffective headache/migraine treatments
F: they are effective treatment options
83
Which of the following are true in regards to combination products such as fiorinal? a. they contain ASA, Caffeine & butalbital + codeine b. they are safe to use in children c. they should be reserved for cases when initial agents fail and in kids between 10-18 yoa d. they have no potential for abuse
a. - they are to be used with caution in children - they are reserved for kids 12-18yoa - they can be a drug of abuse
84
`T/F: Antiemetics can be useful monotherapy for migraines in a pediatric population?
T: N/V occur in 90% of ped migraine sufferers -chlorpromazine -prochlorpezine -metoclopramide
85
Which of the following is correct: a. Ergots are useful in this population because auras are a common feature and trigger the time to treat b. ergots can exacerbate GI upset c. ergots are indicated in all forms of migraine d. it can be used in combo with an antiemetic in the emergency department e. b & d
e. -not for this population because auras are uncommon. Not to be used in complicated migraine d/t risk of vasospasm
86
Which Triptan is specifically indicated for pediatric migraine prevention at 12-18yoa? a. sumatriptan b. zolmitriptan c. almotriptan d. a & c
c. only almotriptan is approved for kids this age, though several have been deemed safe (think ELMOtriptan)
87
T/F: a triptan can be a first line therapy for severe migraines
F: consider for mod/severe migraine that is unresponsive to conventional analgesics
88
Which of the following is false regarding triptans? a. most should not be used with MAOIs/SSRIs b. can cause an unpleasant taste c. they can be used preventively throughout the month d. have many drug interactions e. you cannot use 2 different triptans within 24hrs, even though you can repeat dose of monotherapy up to 2x per 24 hrs
c. they should not be used more than 10days/month
89
How should almotriptan (Axert) be dosed in children >12yoa?
6.25mg at start of headache, then repeated after 2 hours. Do NOT exceed 2 doses/24hrs
90
Which vitamin may be effective in reducing migraine frequency and intensity?
200mg riboflavin
91
Which is the only prophylactic medication that was deemed probably effective based on evidence? a. pizotifen (serotonin antagonist) b. flunarizine (calcium channel blocker) c. propranalol (beta 1 adrenergic antagonist) d. amitryptiline (tricyclic analgesic) e. topirimate(anti-epileptic)
b. flunarizine - a: evidence lacking -c:evidence conflicting, CI airway disease, DM, bradyarrythmias d: studies in kids limited e. approved for adults, used for adolescents
92
What is a reasonable time period to try prophylactic treatment?
6-12 months, then try tapering gradually
93
Which of the following is false? a. there are many controlled trials of pharmacologic management of childhood migraine b. most young patients with migraine do NOT require daily medication c. cyproheptadine is used for prophylaxis in younger children d. adolescents, use propranolol, amitriptyline, naproxen or flunarzine for prophylaxis
A: there are few controlled trials, anecdotal experience prevails
94
T/F: 50% of patients report improvement after 6 months of medical intervention, regardless of the therapy
True
95
What symptoms are associated with h/a in children?
At least one of: vomiting, photophobia, family history of migraine
96
Which should be avoided in children and adolescents for fever or headache associated with viral illness such as varicella or influenza?
ASA
97
Which drug is approved for use in children 12-18 years a. Almotriptan b. Eletriptan c. Frovatriptan d. Rizatriptan e. Sumatriptan
A
98
Best drug for acute migraine in adolescents 12+
Nasal sumatriptan
99
What is the most common s/e of triptans?
Unpleasant taste
100
Best prophylactic agent in childhood
Flunarizine
101
If someon has COPD or asthma or diabetes or bradyarrhythmias or depression can’t use what?
Propranolol
102
Which prophylactic drug is preferred in younger children?
Cyproheptadine
103
Which drugs are for adolescent prophylaxis?
Propranolol, amitriptyline, naproxen or flunarizine
104
Which drugs are CI with triptans?
Ergotamine containing products, SSRI, another triptan, CYP34A inhibitors ie clarithromycin, ketoconazole
105
where is body temperature regulated?
hypothalamus
106
Difference between hyperthermia and fever
In hyperthermia, heat production exceeds heat loss without an increase in regulatory set-point like in fever.
107
Which population cannot mount an elevated temperature in the presence of serious illness but instead remain normothermic or develop hypothermia?
Children <3 months older adults 65yoa and older
108
Is considered fever when the consistent temperature is over what temperature?
38C
109
Febrile responses rarely exceeds 41-42C. T/F
True
110
What is the most frequent cause of fever?
Infections
111
Goals of therapy for fever
-provide patient comfort - balance the benefit of symptomatic tx with possible adverse effects and cost of medication - in children, relieve parental anxiety - in pregnant women during 1st trimester, reduce risk of adverse fetal outcomes
112
T/F Fever is an adaptive response to an infection, often bacterial.
False. fever is an adaptive response to an infection, often viral.
113
Besides infections, fever can occur in: a. malignancy b. rheumatologic diseases c. immunologic diseases d. all of the above
D.
114
who should assess children <6 months of age presenting with fever?
an appropriate health-care practitioner
115
patients assessments when patient presents with fever
- hx and physical exam to ascertain associated sx, sigs, and source of fever - use clinical judgement to determine if underlying process is benign (viral upper resp tract infxn) or life-threatening (bacterial meningitis, pneumonia) - blood cultures when young children have a temperature of >41.1C (bacteremia) - aggressiveness of labs and diagnostic imaging evaluation will depend on severity of illnes, sx pointing to focus infnx, patient's age (especially children <3 months or older adults 65 and >), comorbidities or immunodeficiency
116
Type labs and imaging to determine source of fever: a. c-reactive protein b. culture of suspected source of infx (blood, urine, cerebrospinal fuid) c. chest x-ray d. CBC 1. a, d 2. b, c 3. a, c 4. b, d 5. a, b, c, d
2. b, c: culture of suspected source of infx (blood, urine, cerebrospinal fuid) and chest x-ray c-reactive protein and CBC are non-specific or sufficiently sensitive to replace clinical assessment of the severity of illness.
117
Drugs associated with drug-induced fever
antacid, antibiotics, antihistamines, antipsychotics, barbiturates, carbamazepine, corticosteroids, epinephrine, folic acid, furosemide, insulin, MAOIs, NSAIDs, oral contraceptives, salicylates, vitamins
118
best method of measuring body temperature by age:
oral children > 5yoa and adults rectal children < 2 yoa ear adults axilla children < 5yoa that are low-risk
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normal range for body temp taken orally
35.5-37.5C
120
normal range for body temp taken in the axilla
34.7-37.3C
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normal range for body temp taken in the ear
35.8-38C
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normal range for body temp taken rectally
36.6-38C
123
Nonpharmacologic therapeutic choices for fever LESS than 41C
- remove excess clothing and bedding - increase fluid intake - maintain ambient temp around 20-21C - avoid physical exertion
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Nonpharmacologic therapeutic choices for fever OVER 41-42C
- sponging with tepid or cold water (NOT alcohol) - ice packs or cooling blankets - circulating fans (directed over ice before reaching the patient)
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difference between pharmacologic and nonpharmacologic methods
Pharmacologic methods lower the hypothalamic set-point. Nonpharmacologic methods won't because the body opposes physical cooling.
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goal of antipyretic therapy on pregnant patients
protection of fetus
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goal of antipyretic therapy on non-pregnant patients
patient comfort
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Antipyretic therapy can be justified if...
metabolic demands of fever are greater than the clinical benefits.
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when do you give antipyretic therapy to children?
when they appear distressed or unwell.
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What other effects have antipyretics?
analgesic effects
131
Does antipyretic therapy prevent febrile seizures?
no
132
at what age febrile seizures may occur?
in children between 6 months and 6 yoa
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most common agents used to reduce fever
acetaminophen and ibuprofen
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antipyretic options available for adults
naproxen sodium and ASA
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Is ASA recommended for children or adolescents?
No. because of increased risk of reye syndrome.
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Most recent nonprescription NSAID available for fever
Naproxen sodium
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Naproxen sodium has a longer half-life and can be administer less frequently. T/F
True
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Is there data on use of naproxen sodium for tx of fever in children?
no
139
Which antipyretic is safer than NSAIDs in older individuals who have risk factors predisposing to gastrointestinal and renal toxicity?
Acetaminophen
140
Exposure to fever and other heat sources during 1st trimester of pregnancy is associated with what?
increased risk of neural tube defects and multiple congenital abnormalities
141
Which antipyretic crosses the placenta?
Acetaminophen
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When is acetaminophen relatively safe to use in pregnancy if therapeutic doses are used?
When used short-term.
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What problems can the use ASA and NSAIDs cause if used during pregnancy?
- interferance of labour and premature closure of the ductus arteriosus (could cause persistent pulmonary hypertension in the infant). - ASA causes platelet aggregation in newborns if mother ingest it within 7 days of delivery - salicylates displace bilirubin protein from binding sites - ASA can cause increased bleeding in mother and infants if ingested close to delivery
144
Which trimesters should ASA and NSAIDs be avoided?
1st and 3rd trimesters
145
What dose of ASA is considered compatible with pregnancy?
low-dose ASA 81 mg
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which antipyretics are considered safe during breastfeeding?
acetaminophen and ibuprofen
147
therapeutic tips when using antipyretics
- ask about other concomitant preparations (like cough and cold products), they may have antipyretic content and cumulative dose must be carefully monitored - doses of acetaminophen and ibuprofen are determined by child's weight and not age, a max dose per day should be specified - Concentrations of liquid acetaminophen and ibuprofen vary and caregivers need to check concentration before medication is given - store antipyretics in locked cabinets. acetaminophen is the drug most frequently involved in analgesic overdose in children < 6yoa
148
Some examples of NSAIDs drugs
ibuprofen, advil, motrin, naproxen sodium, aleve, anaprox, naproxen
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Some examples of para-aminophenol derivative drugs
acetaminophen, tylenol, tempra
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Some examples of salicylates drugs
ASA, aspirin
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Adverse effects of NSAIDs
- GI intolerance and bleeding, allergic reactions, tinnitus, visual disturbances, nephropathy - sodium and water retention - dehydration enhances risk of renal toxicity - platelet dysfunction can result in increased bleeding risk
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NSAIDs drug interactions
- increased risk of GI pain/ulceration with alcohol, corticosteroids - antagonist of hypotensive effects of ACE inhibitor, beta-blockers and diuretics - increased risk of bleeding with anticoagulants, SSRIs - increased levels of cyclosporine (and risk of nephrotoxicity) with methotrexate, lithium - reduction of ASA antiplatelet effects when combined with ibuprofen
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para-aminophenol derivatives adverse effects
- hypersensitivity, agranulocytosis anemia - chronic use and overdose associated with hepatotoxicity and nephrotoxicity - potential for toxicity enhanced if concurrent with dehydration, prolonged fasting, DM, obesity, concomitant viral ifnx or family hx of hepatotoxic rxn.
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para-aminophenol derivatives drug interactions
- increased risk of hepatotoxicity with alcohol and isoniazid - decreased acetaminophen levels with enzyme inducers (barbiturates, carbamazepine, phenytoin) - acetaminophen could increase INR in warfarin-treated patients. (Check INR if acetaminophen used 2g or more a day for 3 or more days. Adjust warfarin dose as required.
155
Salicytates adverse effects
- GI upset - avoid in patients with renal failure, peptic ulcer, heart failure and ASA sensitive asthma.
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Salicytates drig interactions
- ASA may decrease therapeutic effect of uricosuric agents (probenecid, sulfinpyrazone) and same as ibuprofen: - GI intolerance and bleeding, allergic reactions, tinnitus, visual disturbances, nephropathy - sodium and water retention - dehydration enhances risk of renal toxicity - platelet dysfunction can result in increased bleeding risk
157
What type of drugs are the mainstay of treatment for cognitive and functional symptoms?
Cholinesterase inhibitors (not be confused with ACE inhibitors = angiotensin converting enzyme) Actions on the parasympathetic nervous system, (the parasympathetic branch of the autonomic nervous system) may cause bradycardia, hypotension, hypersecretion, bronchoconstriction, GI tract hypermotility, and decrease intraocular pressure
158
What are three cholinesterase inhibitors?
Doneprezil, rivastigmine, galantamine
159
T/F: Doneprezil works better than rivastigmine and galantamine?
F: all 3 agents seem to be of equal efficacy
160
T/F: an annual decline of less than 2 points while on the drug therapy indicates a beneficial effect (MMSE scale)
T
161
How often do you monitor treatment or increase a dosage?
Monitor treatment effects 2 weeks after initiating therapy or increasing dosage, then every 3 months
162
Which drug is approved for all disease severities? (mild, moderate and severe)
Donepezil
163
How would you dose Donepezil for Alzheimers?
Start with 5mg usually at night or in the AM if sleep disturbances then increase to 10mg after 4 weeks
164
How would you dose Rivastigmine for Alzheimers?
Start with 1.5 mg BID and increase to 3mg BID after 30 days, max 6mb BID
165
Which drug is good for those who have Lewy body dementia and Parkinson’s Disease?
Rivastigmine
166
Which drug is good for mixed Alzheimer’s disease and vascular dementia?
Glantamine
167
What drug blocks glutamate induced neuronal excotoxicity?
Memantine
168
What drug could you add to donepezil for Alzheimers?
Memantine
169
Which of the following show benefit wrt dementia? A. Ergoloid mesylates B. Vitamin E C. Selegiline D. Gingko biloba E. All of the above F. None of the above
Technically, C. Selegiline proved more effective than placebo but no more effective than vit E alone in delaying death, institutionalization and progression to severe dementia
170
What would you use for vascular dementia?
Lipid lowering agents for dyslipidemia and good control of hypertension
171
Which of the following are good to do to prevent dementia? A. Treat high blood pressure B. Take a baby aspirin daily C. Stake a statin regularly D. Be on estrogen E. 30 min of a brisk walk at least 3 times a week
A and E. Treat high blood pressure, 30 min of a brisk walk at least 3 times a week
172
The preferred method to treat responsive behaviours in dementia is antidepressants. T/F
False, Better to use nonpharmacological interventions like music therapy, aromatherapy, bright light therapy, white nose, massage and touch intervention and involvement in structured recreational activities
173
When choosing an antidepressant, take these factors into account
SSRIs are less likely than TCAs to cause anticholinergic side effects or to worsen orthostatic hypotension, which are common and problematic in this population. - Start at a low dose - Monitor patients for s/e - Increase dosage until recommended range is reached - Maintain therapy for 4-6 weeks after first indication of symptomatic improvement before evaluating the success of treatment (mood, appetite, sleep energy) – can take 6-8 weeks for improvements
174
What could happen if you use thiazide with an SSRI?
Hyponatremia. Monitor electrolytes because of the effect of hyponatremia in cognitive function
175
Which TCAs could you use if not using an SSRI and why
Desipramine or nortriptyline because less anticholinergic effects
176
How long should someone be on antidepressants?
Trial 2-3 months
177
Which two drugs showed benefits in reducing agitation
Sertraline and citalopram
178
Which antipsychotics are first line in dementia?
Risperidone starting at 0.25 mg with 1mg being the optimal dose and 2mg/day the upper limit; olanzapine started at 2.5 mg and increase to 5-10 mg/day They also reduce aggression
179
Which drugs are good to reduce agitation and which aggression in dementia? A. Sertraline B. Citalopram C. Risperidone D. Olanzapine E. Quetiapine F. Aripiprazole
Agitation: A & B & E. Sertraline, Citalopram, Quetiapine Aggresion C & D & F. Risperidone, Olanzapine, Aripiprazole
180
What is the major s/e of risperidone?
Extrapyramidal s/e ie tardive dyskinesia
181
What would you use for someone with a baseline movement disorder or EPS with 2nd generation antipsychosis
Quetiapine
182
T or F there is an increased risk of stroke and death with antipsychotics
T
183
What would you use for someone with AD that has sleep disturbances?
Trazodone 50mg QHS for 2 weeks
184
What should you consider when using antipsychotics?
- Only for severe behavioural symptoms ie psychosis and risk of harming self or others - Use second generation first - Low dose, go up slowly until designated endpoint - Evaluate therapy 1,3, 6 months, then every 6 months – symptoms may subside naturally and the antipsychotic can be tapered - Watch for drug induced akathisis (increased motor restlessness) don’t over dose
185
What type of medication is best avoided in those with Lewy body dementia ,--> rigidity, autonomic dysregulation, cognitive deterioration (delirium)
Antipsychotics
186
Fever due to bacteremia is more likely present if the temperature is:
>41.1 C
187
T/F ASA is recommended in children and adolescents as anti-pyretic drug.
False. It increases the risk of Reye Syndrome.
188
What is Reye syndrome?
a rare but life-threatening illness that affects the brain and liver.
189
Reye Syndrome symptoms
Vomiting: Sudden and prolonged vomiting that may last for hours Sleepiness: Lethargy, unusual sleepiness, or lack of energy Confusion: Mental changes, confusion, or hallucinations Behavior changes: Irritability, aggression, or combative behavior Seizures: Fits or convulsions Loss of consciousness: Coma or difficulty breathing Breathing: Rapid breathing and heart rate Other symptoms: Diarrhea, high-pitched cry, unusual placement of arms and legs, changes in vision, trouble hearing, or abnormal speech
190
When Reye syndrome begins to show after taking ASA?
Usually begins 1–3 weeks after a child recovers from a viral infection, like the flu or chickenpox.
191
Ages Reye syndrome is most common?
It's most common in children between the ages of 4 and 14.
192
What can cause being exposed to fever or other sources of heat during the 1st trimester?
Increased risk of neural tube defects and multiple congenital abnormalities.
193
What antipyretic crosses the placenta and is considered relatively safe for short-term use in pregnancy when therapeutic doses are used?
Acetaminophen
194
Problems taking ASA and NSAIDs during 1st and 3rd trimester of pregnancy cause:
- interference of labour - premature closure if the ductus arteriosus - inhibition of platelet aggregation in mother and child within 7 days of delivery
195
Therapeutic dose of ASA during 2nd trimester of pregnancy
81mg
196
antipyretics safe during breastfeeding
acetaminophen and ibuprofen
197
Why do you ask patients/caregivers or parents about concomitant preparations (especially for cold and flu)?
Because these products have antipyretic content already, therefore needs to be monitored as the effect is cumulative.
198
how to determine therapeutic doses of antipyretics for children
by weight, and must give a max amount per day.

ND Ontario Prescribing Exam (21 decks)

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