Neurology Flashcards
what dose suboxone must one be on for sublocade?- the SQ injection- for how long?
8-24mg for at least 7d
what dose of buprenorphine must one be on to use probuphine (the subdermal implant)?
=<8mg/d
how should methadoen be administered
10mg methadone/mL diluted to make a 100mL solution in orange drink
which has a max dose? methadone or buprenorphine
buprenorphine
which has higher tx retention? methadone or buprenorphine
methadone
if a methadone pt misses 3d of tx, what should be done?
contact MD (always even if <3d)
MD will decrease dose by 50%
what should be done if a methadone pt misses 4 or more days of their methadone?
contact MD (always)
restart at low initial dose ~30mg
what happens if methadone pt vomits dose
offer no more than 50% replacement only if vomited within 15 min and witnessed
when should a naloxone dose be repeated
3min
acamprosate is preferred for patients with ____ insufficiency
hepatic
how long do you hve to be abstinent from alcohol before starting acamprosate
14d
How long do you have to be abstinent from alcohol and opioids before starting naltrexone
alcohol = can start while still drinking
opioids = 7d
how long do you have to be abstinent from alcohol before starting disulfiram
48hrs
what are some complications of AUD
thiamine (B1) deficiency
low electrolytes
liver disease
wernicke’s encephalopathy
what should be nutritionally supplemented in all alcoholics
B1, glucose w/ B1, multivitamins
what is 1st line tx for alcohol w/d
BZDs
which BZDs are more preferred for elderly w/ AWS
lorazepam or oxazepam -intermediate acting BZDs
if the response to BZDs for AWD is not adequate, what can be added
phenobarbital
in short acting opioids, w/d starts in
8-24h
what are the long acting BZDs
diazepam
chlordiazepoxide
flurazepam
what are the short acting BZDs
ATM-alprazolam, triazolam, midazolam
in those on prolonged BZDs tx, taper should be over
6-12wks
T or F: there is currently no approved meds for CNS stimulant withdrawal
T- may use methylphenidate as maintenance
what is the pharm tx rec for chronic fatigue sx
supplementation
short trial of sedating AH or low dose hypnotics
what is a common condition w/ restless leg syndrome
iron deficiency
what is used to tx intermittent RLS
levodopa preps - carbidopa/ levodopa
BZDs
low potency opioids
what is used to tx chronic persistent RLS
GABA derivatives (gabapentin, pregabalin)
nonergot dopamine agonists (pramiprzole, ropinirole, rotigotine)
what may be used for severe refractory RLS in pregnant pts
opioids, BZDs, levodopa/ carbidopa (same as intermittent in normal pt)
THC is a _______ at CB1 and CB2
partial agonist = releases dopamine
CB2 is found ______ aand ____ and is involved in______
throughout immune system and blood cells
involved in immune and inflammatory functions
when does smoking/ vaporising cannabis onset
30s-5min
adults can possess or share ___g legal cannabis aand own up to ___ plants
30g
4 plants
1g dried cannabis = ___g fresh
5
avoid driving for __hrs after eating cannabis, ___ hsr after smoking
8hrs PO, 6hrs INH
what are the 4 conditions cannabis may be used for
neuropathic pain
MS spasticity
CINV
palliative cancer pain
how many neuropathic pain drugs or palliative cancer pain drugs must the pt have tried before cannabis
3 neuropathic
2 cancer
what is the suggested starting dose for cannabis
0.5g/d
1mg nabilone = ___mg THC
10mg
which approved cannabis product in Canada is metabolized by CYP enzymes
nabiximols spray
nabilone is approved for
severe N/V from cancer chemo
migraines have at least 2 of:
nausea, light sensitivity, itnerference w/ activities
MOA can occur with ____ d of simple analgesics or _____ days of opioids/ triptans
15d of simple analgesics
10d of opioids/ triptans
COC with ___ E content may precipitate migraines, ____ E may decrease the frequency
higher E = precipitate
lower E = decrease
what is the algorithm for acute migraines
if causing bed rest = triptans first, then may add NSAIDs
then may trial DHE +/- antiemetic and CGRP inhibitors
if not causing bed rest = simple analgesics with triptans as rescue prn
what is the onset of triptans
30-60min
should you ever repeat a triptan dose
you can after 2hrs, but 2nd dose is unlikely to be helpful if first didn’t provide relief within 2hrs
never mix 2 triptan types within 24hrs
which triptans come as an oral wafer
riza and zolmi
triptans are CI in pts with:
heart disease, cardiac sx, within 24hrs of another triptan, pregnancy
how many types of triptans should you trial
3
which triptan has a clear dose-response relationship
sumatriptan
which triptan has the slowest onset but the least AEs
naratriptan
which triptan should be used with caution in those taking proptanolol and avoided with MAOis
frovatriptan and rizatriptan
which triptan is CI within 72hrs of a potent CYP3A4 inhibitor
eletriptan
CGRP injections are used for _________, while PO are used for __________
inj = prevention
oral = treatment
when should migraine prophylaxis be considered
if migraines are having a significant impact on QoL despite appropriate abortive tx
risk fo MOH
=>4x/mth
how long should migraine prophylaxis be for? how long for benefit?
2mths for benetif
prophylax for 6-12mths
what is considered successful migraine prophylaxis
decrease in at least 50% frequency of days
what is preferred migraine prophylaxis in pts w/ comorbid mood disorder
TCAs (amitriptyline, nortriptyline), venlafaxine
what is preferred migraine prophylaxis in pts w/ comorbid HPTN
BB (propranolol)
candesartan
verapamil (best for cluster)
waht is 1st line for TTH prophylaxis
amitrpytline, nortrityline
what is prophylaxis for pregnancy/ BF Hs
propranolol
which triptan is ok in breastfeeding
sumatriptan
which seizure types have impaired consciousness (5)
complex partial seizures
secondary generalized tonic/ clonic
absence
generalized tonic/clonic
atonic
what are 7 1st line tx for focal seizures
LTG, LEV, LAC, LTG, BRI, OXC, CBZ
(LLLV Boc (LV box))
what is 1st line tx for absence seizures
ETHO
what is 1st line tx for generalized tonic clonic
VPA, LEV, LTG
what is 1st line for atonic seizures
VPA
what is 1st line for myoclonic seizures
VPA, LEV
which AEDs are enzyme inducers
CBZ, eslicarbazepine, oxazepine, PHT, PB, PHT, PRM, rufinamide, topiramate, clobazem
which contraceptive methods are not affected by enzyme inducing AEDs
barrier, IUD, depot progesterone
which AED most likely to cause CNS and GI dose dependent effects
CBZ, LTM, PRN, TOP, VPA
which AED most likely to cause skin rash
LTG, CBZ, PHT
what to do if AED causes skin rash in 1st 6wks
stop and use one that is not LTG, CBZ, PHT
which AED causes neutropenia, which causes thrombocytopenia?
CBZ = neutropenia
VPA = thrombocytopenia
which ED levels decrease in preg
TOLLL
topiramate, oxazepam, LAV, LEV, LTG
____ levels can drop =>50% in pregnancy during 2nd and 3rd trim = 100% dose increase and back to normal dose immed after delivery
LTG
pts on AEDs trying to conceive should take
1mg folic acid from preconception until end of 1st trimester
then 0.4mg/d to prevent neural tube defects
___________ is metabolized into ________
primidone or phenobarb
primidone is metabolized to phenobarb
what is clobazem typiclaly used for in seizures
add on for pts who are nearly seizure free due to broad spectrum + fast onset
what is a AE limiting vigabatrin’s use
permanent vision loss
wha tis a chronic AE of ETHO
behavioural problems
LEV should be avoided in pts w/ a history of ______
psychosis
which ED is associated with SJS and requires very slow titration
LTG
what should be done with LTG after a COC is started
2x LTG dose
which AED is associated with word finding difficulties
topiramate
aim to reduce/ eliminate seizures within ___
1-4wks
when may AED be stopped (typically life long)
seizure free for 2-4yrs or complete control within 1yr
onset between 2-35yrs
normal neuro exam and ECG
which ED requires HLA testing to decrease risk of rash
CBZ
which AED causes hyponatremia and induces its own metabolism
CBZ
Topiramate effect on weight
weight loss
VPA/DVP is ___toxic
hepatotoxic
which NSAIDs should be used if GI risk is high
celecoxib + PPI
which NSAIDs should be used if CV risk is high
naproxen + PPI
what meds are 1st like for neuropathic pain
TCAs, gabepentin/ pregabalin, duloxetine
duloxetine is 1st line for which kinds of pain
peripheral diabetic neuropathy, fibromyalgia
morphine should be avoided in CrCL <
60
which opioids should be avoided in CKD
morphine, codeine, meperidine
which opioids are good for CKD
hydromorphone, methadone
a fentanyl patch should be placed every ____ days
3
how often should methadone be titrated
q3-7d
in opioid management, how much of a decrease in pain intensity indicates efficacious tx
decrease by 30%
how to dose breakthrough pain doses?
when would you increase the TDD instead of adding more breakthrough doses?
10-20% of TDD q1-2hrs if injection, q3-4h if PO
increase schedule doses if pt is using >4-6x/d
how to switch opioids
incomplete cross tolerance = decrease dose by 25-50%
decrease dose by 50% if MEQ >90mg
what is the conversion from codeine to morphine
x0.15
what is the conversion from oxycodone, or hydromorphone to morphine
oxycodone = x1.5
hydromorphone = x5
what MS drug is used for PPMS
ocrclizumab
what deficiency may mimic sx of MS
vit B12 deficiency
MS sx may be worsened by
extremes of temperature
when should a MS pt switch to antoher DMT agent
if =>2 relapses after 6-12mths of tx with a DMT
how long do DMTs take to show benefit
2-6mths
siponimod is used for __________ to delay progression of physical disability
SPMS
what are the 1st line DMTs
T-DIG
teriflunomide, dimethyl fumerate, interferon beta, glatiramer acetate
what is standard 1st line tx for MS
interferon beta
how long for interferon beta to take effect
3mths
glatiramer acetate takes ____ months for effect
6
what to monitor when using dimethyl fumerate
CBC, liver fxn, urinalysis
which of the following should concomitant live vaccines be avoided:
1. interferon beta
2 .glatiramer acetate
3. dimethyl fumerate
4. all of the above
3
teriflunomide has teratogenic effects that may alst up to
2yrs after d/c
how long for teriflunomide to take effect
3mths
in those who become pregnant while on teriflunomide, what should be done
washout with cholestyramine
fampridine is used in MS to
improve walking ability
how long does fampridine take to improve walking ability
4wks
what may be given in acute relapse of MS
methylprednisolone for 3-5d then PO prednisone to decrease length and severity of relapse
what supplementation should be given to all MS pts
vit D (min 1000 IU/d)
fingolimod is for
very active MS disease
natalizumab is for
very active RRMS
how long to try a DMT before switching
6-12 mths
which DMT is most likely to increase QTc
fingolimod
____ (gender) are more likely to get MS and ____ (gender) are more likely to get PD
F = MS
M = PD
waht are the 4 sx of PD
TRAP
tremor, rigidity, akinesia/ bradykinesia, postural instability
T or F: there is no drug that helps with freezing in PD
T
what is a differentiating factor for drug induced PD vs actual PD
drug induced = bilateral and symmetrical
does not or poorely response to L-dopa
when to start tx for PD
when disease starts interfering with QoL
which tx to choose in mild/ early PD
dopamine percursor + dopa decarboxylase inhibitor
MAOBi (in mild)
dopamine agonist
which MAOBi has an amphetamine metabolite
selegiline
which MAOBi has lowered bioavailability w/ high fat meals
rasagiline
anticholinergics are used in PD to
decrease tremor
amantadine is a
NMDA antagonist
what is amantadine used for
used in later stages of PD to reduce L-dopa induced dyskinesias
livedo reticularis is an AE of which PD drug
amantadine
pramipexole, ropinirole, rotigotine are all
nonergot dopamine agonists
dopamine agonists are not recommended in
> 70yrs, hx compulsive behaviours
which dopamine agonist causes pulmonary fibrosis
bromocriptine
levodopa in DP must be (select all that apply)
1. in combo with MAO-Bi to cross BBB
2. in combo with peripheral decarboxylase inhibitor to cross BBB
3. initial tx for >70yrs
4. taken separately from protein meals
5. given as CR dose for freezing
2, 3, 4
what is the purpose of entacapone
a COMTi to extend L-dopa duration to manage wearing off
which PD drug has AE of orange urine discoloration
entacapone
what is used for severe “off” periods in PD
apomorphine
how to manage end of dose wearing off for PD levodopa
increase levodopa dose or frequency
+ DA or COMTi
bedtime admin of levodopa CR or dopamine agonists
change to levodopa CR
MAOBi to reduce fof time
how to reduce peak dose dyskinesias in PD
decrease dose of levo and increase frequency or + dopamine agonist
stop MAO-Bi
decrease dose and + COMTi
add amantadine
which N/V drug may be used in PDs
domperidone
what is the order to stop PD drugs in drug induced psychosis
anticholinergics, TCAs, AH, Anxiolytics, sedatives
Amantadine
DA
COMTi, MAOBi
L-dopa
which antipsychotics may be used in DP
quetiapine, clozapine
