Neurology Flashcards
A physician would like help in choosing an antiepileptic drug (AED) that will not interfere with cyclosporine therapy for a transplant recipient. Assuming that all of the following AEDs will provide adequate seizure control, which AED is most appropriate to use in this patient?
A. Carbamazepine
B. Lacosamide
C. Oxcarbazepine
D. Phenytoin
Answer B, lacosamide is the best answer as no drug-drug interactions exist between lacosamide and cyclosporine. Cyclosporine is a substrate of the CYP3A4 isoenzyme. Carbamazepine and phenytoin at any dose, and oxcarbazepine at higher doses, are all potent inducers of the CYP3A4 isoenzyme and not the best options as they would reduce the serum concentration of cyclosporine. Carbamazepine,
oxcarbazepine, and phenytoin could be given; however, extensive monitoring of cyclosporine concentrations and of signs of organ rejection would be recommended.
Correct Answer: B
Your patient will be admitted for a cholecystectomy.
She takes carbamazepine 400 mg orally three times
daily. She will be unable to take any oral medications
for 3 days after surgery and requires an AED available
as an injectable formulation. Assuming that all of the
following AEDs will provide adequate seizure control,
which is the best AED treatment to recommend during
this time?
A. Carbamazepine
B. Levetiracetam
C. Topiramate
D. Lamotrigine
Answer B, levetiracetam, is correct because it is available as an injectable formulation. Levetiracetam is also available in oral, tablet, and ER formulations. Levetiracetam is 100% bioavailable, so a one-to-one conversion between the intravenous and oral forms can be made when the patient is able to take oral medications. Carbamazepine, topiramate, and lamotrigine are unavailable in an injection formulation; therefore, currently they are not the best choices.
Lamotrigine is available as an orally disintegrating tablet, but it would be inappropriate for this patient because the
tablets are still being absorbed by the GI system.
Correct Answer: B
Carbamazepine is typically initiated at a low dose.
Which is the best reason for starting at a low dose?
A. Precipitation of absence seizures
B. Dizziness caused by initial dose
C. Reduction in risk of rash
D. Reduction in risk of hyponatremia
Answer B, dizziness from the initial dose, is the best
answer. This AE is dose-dependent and can be mitigated by initiating the agent at a low dose. Answer A is not the best reason to initiate at a low dose because carbamazepine will precipitate absence seizures at almost any dose. Answer C is not the best answer because rash is an idiosyncratic reaction that occurs independently of dose. Answer D is
not the best reason. The mechanism of carbamazepine induced hyponatremia is not fully elucidated, but it may
involve osmoreceptor perturbation that develops over time. Initiating the agent at a low dose is not known to reduce the risk of hyponatremia
Correct Answer: B
L.P. is a 46-year-old overweight woman who presents to the clinic with a severe migraine attack. She was given a diagnosis of migraine headaches when she was age 16 years. The patient says her headaches were mostly controlled until about 6 months ago, when they began occurring more often.
She says her migraines usually last 24 hours and occur around the start of her menstrual cycle. She currently has severe pain, nausea, and vomiting. Her home medications include nortriptyline 75 mg orally daily and an oral contraceptive. The patient has a very stressful job and often misses meals. She hydrates with three 32-ounce caffeinated soft drinks throughout the day to “keep her going” and help with her dry mouth. She also reports drinking red wine
regularly in the evening to calm down after a difficult day. Because of her stressful job, her sleep schedule is sporadic.
Which is the most appropriate nonpharmacologic
therapy to recommend for this patient?
A. Change to diet soda.
B. Limit red wine consumption.
C. Begin taking naps during the day.
D. Subscribe to a weight management program.
Avoiding migraine triggers is a good nonpharmacologic
option for patients with migraines. Migraine triggers
include skipping meals, sleep deprivation, excessive
amounts of sleep, red wine, changes in weather, fragrances, caffeine, and certain types of foods. In the patient case, the migraines are possibly triggered by stress, missed meals, caffeine consumption, alcohol intake, and a sporadic sleep schedule. Although these triggers are best avoided, abruptly discontinuing a highly caffeinated beverage such as Mountain Dew could cause rebound headaches. The patient should be counseled to wean off caffeine rather than discontinuing it abruptly. Also, the diet soda version of her soft drink would still likely be caffeinated, making Answer A incorrect. She should limit her red wine consumption to determine whether it is her main trigger.
Correct Answer: B
L.P. is a 46-year-old overweight woman who presents to the clinic with a severe migraine attack. She was given a diagnosis of migraine headaches when she was age 16 years. The patient says her headaches were mostly controlled until about 6 months ago, when they began occurring more often.
She says her migraines usually last 24 hours and occur around the start of her menstrual cycle. She currently has severe pain, nausea, and vomiting. Her home medications include nortriptyline 75 mg orally daily and an oral contraceptive. The patient has a very stressful job and often misses meals. She hydrates with three 32-ounce caffeinated soft drinks throughout the day to “keep her going” and help with her dry mouth. She also reports drinking red wine
regularly in the evening to calm down after a difficult day. Because of her stressful job, her sleep schedule is sporadic.
Which is the best option for preventing migraines in
this patient?
A. Continue nortriptyline at 75 mg/day.
B. Increase nortriptyline to 150 mg/day.
C. Discontinue nortriptyline; start propranolol 80
mg/day.
D. Discontinue nortriptyline; start candesartan 16
mg/day.
Answer A is incorrect because the patient’s preventive
drug and dose has not been effective for the past 6 months. While tricyclic antidepressants (e.g., nortriptyline) are a good option for preventing migraines, they often have many AEs (e.g., anticholinergic issues). The patient is noted to have dry mouth. Answer B is incorrect because increasing the nortriptyline dose could worsen this AE. For this reason, it would be best to discontinue nortriptyline and trial an alternative preventive therapy. Candesartan (Answer D) does not have as much data on migraine prophylaxis as propranolol. Propranolol (Answer C) is a good option for preventing migraines because it has Level A evidence for preventing migraines and is not associated with many AEs at low doses.
Correct Answer: C
L.P. is a 46-year-old overweight woman who presents to the clinic with a severe migraine attack. She was given a diagnosis of migraine headaches when she was age 16 years. The patient says her headaches were mostly controlled until about 6 months ago, when they began occurring more often.
She says her migraines usually last 24 hours and occur around the start of her menstrual cycle. She currently has severe pain, nausea, and vomiting. Her home medications include nortriptyline 75 mg orally daily and an oral contraceptive. The patient has a very stressful job and often misses meals. She hydrates with three 32-ounce caffeinated soft drinks throughout the day to “keep her going” and help with her dry mouth. She also reports drinking red wine
regularly in the evening to calm down after a difficult day. Because of her stressful job, her sleep schedule is sporadic.
Based on duration of action, which is the best option
for abortive treatment of this patient’s migraines?
A. Sumatriptan 50 mg
B. Frovatriptan 2.5 mg
C. Rizatriptan 5 mg
D. Almotriptan 6.25 mg
Triptans are good options for the abortive treatment of
migraines. Although all are good agents, selection of a
triptan should be tailored to the individual patient. This
patient’s migraines usually start around her menstrual cycle and generally last 24 hours; thus a long-acting triptan would be preferable. When migraines occur around the menstrual cycle, it is appropriate to give a triptan with a long half-life before the menstrual cycle begins and to continue it for 2 days after the cycle is finished. The two triptans with a long half-life are frovatriptan (half-life 26 hours) and naratriptan (half-life 6 hours). Answers A, C, and D are not the best
choices because sumatriptan, rizatriptan, and almotriptan
all have half-lives shorter than 5 hours.
Correct Answer: B
A 50-year-old man comes to the clinic seeking abortive treatment for his migraine headaches. The patient
has a history of benign prostatic hyperplasia, depression, and hypercholesterolemia. His home medications include tamsulosin 0.4 mg/day, selegiline 9 mg/24- hour patch, and simvastatin 20 mg/day. Considering potential drug interactions, which is the best abortive treatment option for his migraine headache?
A. Eletriptan
B. Rizatriptan
C. Sumatriptan
D. Zolmitriptan
This patient currently takes a nonselective monoamine oxidase (MAO) inhibitor for depression, selegiline (Emsam patch). Administering triptans that are metabolized by MAO in addition to a nonselective MAO inhibitor should be avoided. Triptans that are at least partly metabolized by MAO include almotriptan, rizatriptan, sumatriptan, and zolmitriptan (Answers B, C, and D are incorrect). Answer A (eletriptan) is the best choice because it is not metabolized by MAO. Of note, MAO inhibitors used for PD at recommended doses maintain specificity for MAO-B and are thus selective MAO inhibitors. These medications
(selegiline oral formulations, rasagiline, and safinamide) do not have clinically significant interactions with triptans metabolized by MAO.
Correct Answer: A
A 68-year-old man has localized neuropathic pain for
whom antidepressant and AED therapies have failed
(because of sedation). He had a fall while taking nortriptyline. He has hypertension (HTN) on lisinopril
and a history of a gastrointestinal (GI) bleed. Which
would be the best recommendation to treat his pain?
A. Topical lidocaine patch
B. Naproxen
C. Oxycodone/acetaminophen
D. Lamotrigine
The patient has localized pain and has not tried a topical product. Given that the patient has had adverse effects with other systemic therapies, a topical product is a good option that will not cause systemic adverse effects (Answer A is correct). Answer B is incorrect because it is beneficial for
musculoskeletal pain, not neuropathic pain, and the patient has a history of a GI bleed. Answer C is incorrect because safer, non-opioid options can still be tried. Answer D is incorrect because lamotrigine has minimal evidence for neuropathic pain, and options with greater efficacy should be tried first.
Correct Answer: A
A patient requires appropriate therapy for his mild to
moderate pain. He currently takes no medications for
chronic pain. In conjunction with education on nonpharmacologic methods, which would be the most
appropriate first step in therapy for a duration of 5
days?
A. Ibuprofen 400 mg three times daily
B. Acetaminophen/hydrocodone 500 mg/10 mg as 1
tablet every 4–6 hours as needed
C. Tramadol 50 mg three times daily
D. Celecoxib 200 mg daily
Ibuprofen would be the best option for this patient, whose pain is most likely inflammatory in origin. Short-acting opioids would be an option if his pain were moderate to severe or if he had not responded to therapy with a milder agent. Celecoxib, a COX-2–specific agent, would not be considered as a first-line agent in this case because the patient has no history of GI disorders or experiences of failure with other NSAID therapies. Celecoxib is considerably more costly than ibuprofen.
Correct Answer: A
A 40-year-old man presents with newly diagnosed
myasthenia gravis (MG). He has bilateral upper
extremity muscle weakness, sagging of the right side
of his face, drooping of his right eyelid, and fatigue.
He is given a new prescription for pyridostigmine
today at his neurology office visit. Which is the most
appropriate information to provide the patient regarding his medication?
A. Pyridostigmine is indicated to help prevent the
further progression of MG.
B. Pyridostigmine should be taken only on an as needed basis to prevent the development of
tolerance.
C. The most common adverse effects include abdominal cramping, diarrhea, nausea, and vomiting.
D. The effect of the drug can be seen only 1–2 weeks
after treatment initiation
The most commonly reported AEs of pyridostigmine are
related to its cholinergic properties. Pyridostigmine is primarily used to improve muscle strength in MG but does not alter disease progression. It is administered on a regular basis, and the development of tolerance is not known to be associated with frequency of use. Pyridostigmine provides symptomatic relief, and the clinical effect occurs within 10–15 minutes.
Correct Answer: C
A 24-year-old woman was recently given a diagnosis
of relapsing-remitting multiple sclerosis (RRMS). She
currently describes minimal disability. Magnetic resonance imaging (MRI) reveals one white matter brain lesion; no demyelinating lesions are seen on her spinal cord. She is severely depressed, and she is not taking an antidepressant. Taking a risk-stratified approach, which disease-modifying therapy (DMT) is most appropriate to use for this patient?
A. Interferon β-1a
B. Interferon β-1b
C. Glatiramer acetate
D. Fingolimod
The best answer currently is glatiramer acetate because of this patient’s untreated depression and new diagnosis of RRMS. Neither Answer A (interferon β-1a) nor Answer B (interferon β-1b) is the best choice currently because of the patient’s untreated depression, which is a possible AE of interferons. Answer D (fingolimod) is not the best choice
currently because the patient has minimal disability and risk factors, which suggest less active disease. Fingolimod is a highly effective DMT most appropriate for patients with risk factors suggesting highly active disease and has a more extensive AE profile, although it is not associated with causing worsening depression. In addition, the clinician should encourage the patient to be on highly effective contraception if starting fingolimod because of the possible teratogenic risks
Correct Answer: C
A 28-year-old female patient with multiple sclerosis (MS) is having relapses more often and has been
treated with interferon β-1a for the past 3 years. She
prefers an oral agent to address her relapses, and she
wants to start a family in 5 years. Which is the best
DMT to recommend now?
A. Mitoxantrone
B. Teriflunomide
C. Dimethyl fumarate
D. Glatiramer acetate
Of the choices given, dimethyl fumarate is best for this
patient right now (Answer C). Its safety profile in pregnancy is also more favorable than the other DMT choices. Answer A is not the best choice currently because of the AE profile for mitoxantrone (secondary leukemias) and its intravenous administration. Although oral, Answer B is not the best choice because teriflunomide is pregnancy category X, and an accelerated elimination procedure with cholestyramine or activated charcoal would be necessary before pregnancy. If an accelerated elimination procedure
is not done, teriflunomide can take as long as 2 years to reach undetectable blood concentrations. Answer D is not the best option currently because glatiramer acetate has efficacy similar to her current DMT, which is not controlling her disease. Moreover, the patient prefers an oral agent and glatiramer acetate is given subcutaneously
Correct Answer: C
A 71-year-old woman is seen in the clinic for a routine
annual visit. As part of the evaluation, a Mini-Mental
State Examination (MMSE) is performed, on which
she scores 23/30. Her score 1 year ago was 26/30.
Her medical conditions include HTN, osteoporosis,
hypothyroidism, and overactive bladder. Her current
medication list includes hydrochlorothiazide 12.5 mg/
day, lisinopril 10 mg/day, alendronate 70 mg once
weekly, calcium/vitamin D 500 mg/400 international
units twice daily, levothyroxine 100 mcg/day, and tolterodine 4 mg/day. Her blood pressure is controlled at 132/84 mm Hg, and examination results are otherwise unremarkable. A thyroid-stimulating hormone measurement 2 months ago was 2.2 mIU/L. Which factor is most likely contributing to this patient’s cognitive changes?
A. Hypothyroidism
B. Alzheimer disease
C. Tolterodine
D. Levothyroxine
This patient has experienced cognitive decline during the past year, as indicated by the change in MMSE scores. The decline in MMSE score and the score of 23/30 are not diagnostic for AD or dementia. Hypothyroidism can contribute to cognitive symptoms; however, this patient had a normal thyroid-stimulating hormone reading 2 months ago. Alendronate is not commonly known to cause cognitive symptoms. Tolterodine, however, can affect cognitive functioning because of antimuscarinic effects, particularly
in patients who may have cognitive impairment at baseline. Similarly, other nonspecific muscarinic blockers (e.g., oxybutynin, diphenhydramine) are associated with cognitive symptoms.
Correct Answer: C
A 77-year-old man with recently diagnosed probable Alzheimer disease (AD) (MMSE 22/30) began
treatment with galantamine ER 8 mg/day 3 months
ago. After taking this dose for 1 month, his dose was
titrated to galantamine ER 16 mg/day, but he experienced intolerance because of nausea; therefore, the dose was decreased to the original dose of 8 mg/day. He continued this dose for 6 more weeks without adverse effects (AEs), so his dose was again titrated to 16 mg/day about 1 week ago. The patient’s wife calls the clinic today to report that her husband’s symptoms have not improved, he has been having nausea, and he has not eaten well since the dose increase. Which is the best treatment strategy for this patient?
A. Discontinue galantamine; initiate donepezil 5 mg/
day.
B. Decrease the galantamine ER dose to 8 mg/day.
C. Discontinue galantamine; initiate memantine 5
mg/day.
D. Discontinue galantamine; initiate rivastigmine 6
mg twice daily.
The most common AEs of the cholinesterase inhibitors as a class are GI in nature, including nausea, vomiting, and diarrhea. Dose titration reduces the likelihood of intolerability. This patient has been unable to tolerate galantamine 16 mg/day, the minimally effective (target) dose from clinical studies; thus, galantamine at this dose should be discontinued. Initiating memantine could be considered in patients with moderate to severe AD; however, this patient has mild AD, given the patient’s recent MMSE score of 22/30. Clinical studies show that memantine has negligible benefit on the cognitive and functional status of patients with mild AD. Some individuals tolerate one cholinesterase inhibitor better than another; therefore, changing this patient’s medication to a different cholinesterase inhibitor would be appropriate. From accumulated clinical data,
fewer patients describe GI intolerability with donepezil
than with rivastigmine. Furthermore, the rivastigmine dose of 6 mg twice daily is the target dose, not the starting dose. Initiating rivastigmine at 6 mg twice daily could induce severe symptoms of nausea and vomiting.
Correct Answer: A
A 72-year-old woman will begin treatment with the
rivastigmine patch for moderate AD. Which is the best
information to provide the patient and caregiver?
A. Liver function tests will be required during the
first 12 weeks.
B. The drug will significantly improve the symptoms
of the disease.
C. Adding vitamin E to rivastigmine will improve
the efficacy of the drug.
D. Medications such as diphenhydramine or chlorpheniramine should be avoided while taking this
drug.
Rivastigmine does not require liver function test monitoring. Tacrine, the first drug approved to treat AD but has since been withdrawn because of its association with liver toxicity. Currently no data suggest that concurrent use of vitamin E with cholinesterase inhibitors improves efficacy. The clinical effects of cholinesterase inhibitors are very modest, so
patients and families should have reasonable expectations for what the medications can achieve. Anticholinergic medications can reduce the efficacy of cholinesterase inhibitors and worsen the cognitive symptoms of the disease, so they should be avoided in patients with AD.
Correct Answer: D
A 76-year-old woman has taken donepezil 10 mg/day
for 11 months and has tolerated it well, except for mild
to moderate nausea on rare occasions. She is in the clinic today with her daughter, who is concerned about her mother’s worsening memory and daily functioning. The patient’s MMSE score today is 15/30 compared with 19/30 1 year ago. No evidence of acute medical problems is found during the examination, and a depression screen is negative. Which is the most appropriate recommendation now to address the daughter’s concerns?
A. Increase donepezil to 23 mg/day.
B. Decrease donepezil to 5 mg/day.
C. Continue donepezil; add memantine therapy.
D. Discontinue donepezil and monitor.
The donepezil 23-mg tablet dosage form was approved for use in patients who have been taking and tolerating donepezil 10 mg/day for 3 months or longer. Clinical studies have shown a small clinical benefit in post-hoc analysis of the 23-mg dose compared with the 10-mg dose. However, the incidence of GI AEs (i.e., nausea, vomiting, diarrhea, weight loss, anorexia) was much higher with the 23-mg
dose. The patient has occasional nausea with the lower 10-mg dose. Decreasing the donepezil dose may help the patient’s occasional nausea symptoms, but it will not address her worsening AD symptoms. Adding memantine to donepezil may provide additional clinical benefit beyond the use of either donepezil or memantine alone and a trial should be started. No evidence suggests that the patient has lost the ability to speak, ambulate, or provide self-care, so it is reasonable to continue therapy as long as it is not causing significant AEs.
Correct Answer: C
A 64-year-old man with HTN, osteoarthritis, type
2 diabetes, renal insufficiency (estimated creatinine
clearance 25 mL/minute/1.73 m2), and gastroesophageal reflux disease presents to the clinic with symptoms of rigidity in the upper extremities, mild hand tremors, and gait changes. He takes hydrochlorothiazide 25 mg once daily and amlodipine 5 mg once daily for HTN; ibuprofen 400 mg twice daily as needed for osteoarthritis; glipizide 5 mg twice daily for type 2 diabetes; and metoclopramide 10 mg four times daily and omeprazole 20 mg once daily for gastroesophageal reflux. He states that the symptoms are difficult for him to tolerate and affect his functioning. Which is the best initial recommendation for addressing this patient’s symptoms?
A. Add levodopa/carbidopa 100/25 mg three times
daily.
B. Add ropinirole 0.25 mg twice daily.
C. Discontinue metoclopramide 10 mg four times
daily.
D. Discontinue amlodipine 5 mg once daily
Before initiating therapy for possible PD, patients should
be screened for the possibility of drug-induced symptoms, such as from antiemetics or antipsychotics. Because of dopamine-blocking activity, metoclopramide can induce PD-like features. In addition, because metoclopramide is renally eliminated, it can accumulate in patients with impaired renal function, increasing the likelihood of AEs. The metoclopramide dose should slowly be reduced, to prevent withdrawal symptoms, to the minimally effective dose or discontinued completely, if possible.
Correct Answer: C
A 72-year-old man presents to the clinic with a 6-month
history of intermittent tremor in his hands and difficulty
with his gait. He states that his symptoms have worsened since his last visit 3 months earlier. Laboratory test results and a computed tomography scan at his previous visit were normal. Physical examination reveals a resting hand tremor, greater in the left hand than in the right, which ceases with purposeful movement. It also shows mild cogwheel rigidity in both elbows, left greater than right. Postural reflexes and balance assessments are mildly abnormal. A gait assessment reveals reduced arm swing while walking. He states that the symptoms are affecting his daily life and that he is concerned about his ability to continue working. From his medical history and physical examination, he is given a diagnosis of Parkinson disease (PD). Which is the most
appropriate initial therapy for this patient?
A. Benztropine 0.5 mg twice daily
B. Coenzyme Q10 900 mg daily
C. Levodopa/carbidopa 100/25 mg three times daily
D. Pramipexole 1 mg three times daily
This patient is 72-years-old, thus a levodopa-centered
approach can be taken because this agent is most effective for PD symptom management. Anticholinergic agents such as benztropine would be considered if the patient’s predominant symptom was tremor. Many patients, particularly older patients, do not tolerate anticholinergic agents well (AEs include confusion, constipation, dry mouth, and urinary retention), and anticholinergic agents would not be appropriate as first-line therapy in this older adult patient. One study with coenzyme Q10 showed functional benefits when dosed at 1200 mg/day. However, current recommendations do not support the initiation of coenzyme Q10 as initial treatment of PD. Pramipexole would be an
appropriate first-line treatment for PD if a levodopa-sparing approach were chosen (typically for younger patients). Also, a dose of 1 mg three times is too high for an initial starting dose; 0.125 mg three times daily would be a more appropriate starting dose.
Correct Answer: C
A 68-year-old woman with a recent diagnosis of PD
began treatment with levodopa/carbidopa 100/10 mg
three times daily 5 days ago. She calls the clinic to
report symptoms, including nausea and light-headedness. She states that her PD symptoms are improved and that her ability to move around and function is better, but the AEs are difficult to tolerate. Which is the best recommendation for this patient?
A. Continue levodopa/carbidopa; add rasagiline 0.5
mg/day.
B. Decrease levodopa/carbidopa dose to 100/10 mg
twice daily.
C. Discontinue levodopa/carbidopa; add ropinirole
0.25 mg three times daily.
D. Change levodopa/carbidopa dose to 100/25 mg
three times daily
The common AEs of levodopa at initiation of therapy
include nausea, vomiting, dizziness, and hypotension.
Adding a DOPA decarboxylase inhibitor such as carbidopa can considerably reduce these peripheral AEs. The carbidopa dose needed to saturate peripheral DOPA decarboxylase is 75–100 mg/day. This patient is only receiving 30 mg of carbidopa daily. Changing the levodopa/carbidopa dosage formulation from 100/10 mg three times daily to 100/25 mg three times daily would increase the carbidopa intake to 75 mg/day. Adding rasagiline to levodopa therapy would not resolve the patient’s symptoms and might actually make them worse. Decreasing the levodopa/
carbidopa 100/10-mg dose from three times daily to twice daily might reduce the AEs, but the carbidopa dose would still be insufficient, and the lower daily levodopa dose might reduce the control of her PD symptoms.
Correct Answer: D
A 72-year-old woman with PD has taken levodopa/
carbidopa for more than 6 years. Her current dose is
100/25 mg, 2 tablets in the morning and 1 tablet at
noon, 4 p.m., and 8 p.m. She has motor complications
(on/off symptoms, wearing-off) related to chronic
levodopa therapy, so her physician added rasagiline 1
mg once daily in the morning to her regimen 1 week
ago. She is in the clinic today and reports having AEs
since the new medication was added, including nausea
and involuntary movements, which are identified on
examination as dyskinesias. Which is the best recommendation for this patient?
A. Discontinue rasagiline; add selegiline 5 mg twice
daily.
B. Decrease levodopa/carbidopa dose to 100/25 mg
1 tablet in the morning and at noon, 4 p.m., and
8 p.m.
C. Discontinue rasagiline; add ropinirole 0.25 mg
twice daily.
D. Continue levodopa/carbidopa and rasagiline; add
amantadine.
Abnormal involuntary movements such as dyskinesias
suggest excessive dopaminergic treatment. Nausea in the context of abnormal involuntary movements can also be a sign of excessive dopaminergic treatment. When a second drug is added to levodopa therapy—whether a MAO-B inhibitor, a COMT inhibitor, or a dopamine agonist—most patients require a decrease in the levodopa dose to avoid possible dopamine-related AEs (e.g., dyskinesias, nausea or vomiting, hallucinations). Decreasing the levodopa dose would be the best initial approach to managing this problem. Changing from rasagiline to selegiline or ropinirole would still be associated with a similar problem and would
likely necessitate a reduction in the levodopa dose. While amantadine is used to treat dyskinesias, a small decrease in levodopa dose (answer B) is the best answer at this time before adding a third agent to the patient’s regimen.
Correct Answer: B
Name 8 narrow spectrum meds tx focal seizures
Brivaracetam
Carbamazepine
Eslicarbazepine
Oxcarbazepine
Pregabalin
Lacosamide
Phenytoin
Cenobamate
Name a narrow spectrum drug that tx generalized seizure
Ethosuximide
Name 8 BROAD spectrum that treats focal and generalized seizures
Clobazam
Lamotrigine
Levetiracetam
Perampanel
Phenobarbital
Rufinamide
Topiramate
Valproate
Which three anti-epileptic drugs are moderate inducers and which two are those basedondose
Oxcarbazepine >1200mg
Topiramate>200mg
Eslicarbazepine
Which anti-seizure medication has zero order kinetics
Phenytoin
Small changes in dose can lead to higher concentration rapidly
