Neurology Flashcards
1
Q
- 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
A
- Answer: B
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
2
Q
- 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
A
- Answer: B
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.
3
Q
- 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
A
- Answer: B
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 carbamazepineinduced 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
4
Q
Questions 4–6 pertain to the following case.
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. - 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. - 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
A
- Answer: B
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 - Answer: C
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. - Answer: B
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
5
Q
- 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
A
- Answer: A
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
Neurology
ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
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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.
6
Q
- 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) currently treated with 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
A
- Answer: A
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.
7
Q
- 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
A
- Answer: A
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.
8
Q
- 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 asneeded 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.
A
- Answer: C
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
9
Q
- 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
A
- Answer: C
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.
10
Q
- 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
A
- Answer: C
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
11
Q
- 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
A
- Answer: C
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
12
Q
- 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?
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ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
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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
A
- Answer: A
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.
13
Q
- 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
A
- Answer: D
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
14
Q
- 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
A
- Answer: C
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
15
Q
- 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
A
- Answer: C
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.
