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BCPS > Neurology > Flashcards

Neurology Flashcards

1
Q

Focal seizure

A

affects one side of the brain

Aware or impaired awareness
Motor or nonmotor
Focal or bilateral tonic-clonic

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2
Q

Generalized onset

A

Affects both sides of the brain

Absence (nonmotor)
Myoclonic (motor) - brief jerking movements

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3
Q

Tonic-clonic

A

5 phases:
Flexion
Extension
Tremor
Clonic
Postictal

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4
Q

Status epilepticus

A

Prolonged seizure of >5 minutes

After 30 minutes, long-term consequences possible

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5
Q

Automatisms

A

Associated with focal seizures - may occur before seizure

Lip smacking, chewing, swallong, tongue movements, scratching, thrashing arms/legs, fumbling with clothing, snapping fingers

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6
Q

Carbamazepine alleles

A

HLA-B*1502 - increased risk of SJS (Asian population)

HLA-B*3101 - increased risk of hypersensitivity (not tested routinely)

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7
Q

Phenytoin equivalents (PE)

A

1.5mg fosphenytoin = 1mg phenytoin (1 PE)

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8
Q

Dosing, administration rate fosphenytoin

A

Load: 10-20mg PE/kg IV or IM
Maintenance: 4-6 PE/kg/day in divided doses after load

Max infusion rate 150mg PE per minute (risk of severe hypotension, cardiac arrhythmias)

Less risk of phlebitis than phenytoin

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9
Q

Lamotrigine & Valproic Acid

A

Valproic acid decreases lamotrigine concentration

Lower starting and maintenance doses of lamotrigine needed to prevent ADRs

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10
Q

Estrogen effects on antiepileptics

A

Lamotrigine: estrogen OCPs increase clearance of lamotrigine so higher doses needed

Valproic acid: estrogen OCPs decrease VPA serum concentration

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11
Q

Antiepiletic drugs that are enzyme inducers

A

Carbamazepine
Cenobamate (CYP3A4)
Fosphenytoin
Oxcarbazepine
Phenobarbital
Phenytoin
Primidone
Vigabatrin (CYP2C9)

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12
Q

Phenytoin drug interactions

A

Increase phenytoin:
Anticoagulatns
Chloramphenicol
Cimetidine
Diltiazem
Disulfiram
Isoniazid
Phenybutazone
Sulfa-TMP

Decreased phenytoin:
Antineoplastics
Diazoxide
Folic acid
Rifampin

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13
Q

Carbamazepine drug interactions

A

Decrease carbamazepine:
Theophylline

Increase carbamazepine:
Cimetidine
Diltiazem, verapamil
Erythromycin
Isoniazid
Nefazodone

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14
Q

Valproic Acid drug interactions

A

Increase VPA:
Salicylates

Decreased VPA:
Estrogen OCPs
Meropenem
Rifampin

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15
Q

Carbamazepine therapeutic level

A

4-12 mcg/ml

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16
Q

Phenobarbital therapeutic level

A

15-40 mcg/ml

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17
Q

Phenytoin therapeutic level

A

10-20 mcg/ml

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18
Q

Valproic acid therapeutic level

A

40-100 (150) mcg/ml

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19
Q

Zonisamide cross reactivity

A

Avoid in patients with sulfa allergy

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20
Q

Lamotrigine starting dose

A

Typical: 25mg daily

with VPA: 25mg every other day

with inducers (carbamazepine, phenytoin, phenobarbital, primidone): 50mg daily

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21
Q

Status epilepticus Principles

A
  1. Ascertain ABCs
  2. Obtain lab (BG, BMB, BMP, Ca, Mg, serum conc)
  3. BG < 60: admin thiamine 100mg IV followed by D50%
  4. Administer emergency medication to stop seizure
  5. Administer urgent medication to prevent seizure

Administer drugs parenterally. Do not administer NMBAs.

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22
Q

Emergency Meds for Status Epilepticus

A

Lorazepam (DOC) 0.1mg/kg (max 4mg) at rate of 2mg/min

Diazepam 0.15mg/kg (max 10mg) at rate of 5mg/min

Midazolam (IM) 0.2mg/kg (max 10mg)

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23
Q

Urgent Meds for Status Epilepticus

A

FDA approved:
Phenytoin 20mg/kg
Fosphenytoin
Phenobarbital 20mg/kg

Non-FDA approved:
Valproic Acid 20-40mg/kg
Levetiracetam 40-60mg/kg
Lacosamide 200-400mg bolus

24
Q

Refractory status epilepticus meds

A

If BZD resistant: fosphenytoin, levetiracetam, or valproate

Pentobarbital (ventilator)
Midazolam drip
Propofol (ventilator)

25
Q

Epilepsy in Pregnancy

A

Avoid valproate acid as much as possible in nonpregnant and pregnant women

Avoid phenytoin, carbamazepine, and phenobarbital

Consider monitoring serum concentrations during pregnancy

26
Q

Antiepileptics that decrease effect of OCP, patch, ring, progesterone implant

A

Carbamazepine
Lamotrigine
Oxcarbazepine
Phenobarbital
Phenytoin
Primirdone
Topiramate (>200mg)

Others: brivaracetam, cenobamate, clobazam, eslicarbazepine, felbamate, perampanel, rufinamide

Recommend Medroxyprogesterone injection or levonorgesterol IUD

27
Q

Suicide risk in antiepileptics

A

All anti-epileptic meds have this warning (most siG: levetiracetam, phenobarb, primidone, topiramate, vigabatrin, tiagabine, perampanel)

Increased risk between week 1 thru week 24 of therapy

28
Q

Wearing-off phenomenon

A

Assoc w/ Carbidopa/Levodopa

Return of Parkinson’s symptoms before next dose

Add on therapies: DA agonist, MAO-B inhibitor, COMT inhibitor (entacapone, opicapone), increasing frequency/dose of levodopa

29
Q

On-off phenomenon

A

Assoc with Carbidopa/Levodopa

Unpredictable return of Parkinson disease symptoms without respect to dosing interval

Add on therapies: entacapone, MAO-B inhibitors (rasagiline, selegiline), DA agonist (pramipexole, ropinirole, apomorphine)

30
Q

Dyskinesia in PD

A

Assoc w/ Carbidopa/Levodopa

Drug-induced involuntary movements

Treatment: decrease levodopa dose, add amantadine

31
Q

MAO-B inhibitors

A

Increase dopamine in brain

Selegiline
Rasagiline
Safinamide

Caution serotonin syndrome (meperidine, other serotonergic meds)

Available as tabs and ODTs. Metabolized to amphetamine. Rasagiline interacts with Ciprofloxacin.

32
Q

Carbidopa/levodopa

A

Carbidopa prevents peripheral conversion of levodopa to dopamine, thus increasing amount of levodopa to cross BBB and increase dopamine

Long-term ADRs = wearing-off phenomenon, on-off phenomenon, dyskinesias

Slow release as delay to effect so may need to combine with IR form

Greatest benefit for rigidity and bradykinesia > tremor, postural instability

32
Q

Dopamine agonists

A

Apomorphine
Bromocriptine
Pramipexole
Ropinirole
Rotigotine

Titrate to effect
Dopamine related ADRs - impulsive behavior, N/V, postural hypotension

33
Q

Apomorphine

A

DA agonist that treats off-episodes by SC inj

CI: 5HT3 antagonists (ondansetron, etc), sulfite allergy

Trimethobenzamide helps nausea

Complex dose initiation, must be done in setting w/ BP monitoring

34
Q

Anticholinergics for PD

A

Trihexyphenidyl, benztropine

Useful only for tremor

35
Q

Amantadine for PD

A

Reduces dyskinesias

36
Q

COMT inhibitors

A

Prevent breakdown of dopamine to increase amount of levodopa crossing BBB
Must be used with carbidopa/levodopa

Tolcapone (severe restriction)
Entacapone
Opicapone

Diarrhea may occur after 2 weeks of initiation
Orange urine

37
Q

Pimavanserin

A

approved for PD psychotic disorder

38
Q

Antipsychotic preference in PD

A

Quetiapine or clozapine

Avoid typical antipsychotics, risperidone, olanzapine as they worsen motor features

39
Q

Migraine highlights

A

Unilateral, pulsating, mod-severe intensity, aggravation by walking

Nausea, vomiting, photophobia, phonophobia

+/- aura

40
Q

Tension headache highlights

A

Pressing or tightening (nonpulsating), mild-moderate, bilateral, no aggravation with walking

41
Q

Cluster headache highlights

A

Several episodes of unilateral, orbital, supraorbital or temporal pain

Conjuctival injection, lacrimation, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis, eyelid edema

42
Q

Calcitonin gene-related peptide antagonists

A

Refractory prophylaxis:

SC:
Erenumab-aooe (aimovig)
Fremanezumab-vfrm (ajovy)
Galcanezumab-gnlm (emgality)

IV:
Eptinezumab (vyepti)

PO:
Atogepant (qulipta)
Rimegepant (Nurtec ODT)

Acute:

Ubrogepant
Rimegepant
Zavegepant (intranasal)

43
Q

Alternate routes for triptans

A

SC:
sumatriptan

Intranasal:
sumatriptan
zolmitriptan

ODT:
zolmitriptan
rizatriptan

44
Q

Triptan & Ergot CI

A

CAD
stroke
uncontrolled HTN
peripheral vascular disease
ischemic bowel disease
pregnancy

45
Q

Triptan DI

A

MAO-I (do not use within two weeks)

Propranolol & rizatriptan (propranolol 5mg max per dose)

46
Q

Antiemetics for migraine

A

Prochlorperazine
Metoclopramide
Chlorpromazine

47
Q

Tension HA Prophylaxis

48
Q

Tension HA Acute Tx

A

APAP
NSAIDs (aspirin, ibuprofen, naproxen, ketoprofen, ketorolac)
w or w/o caffeine

49
Q

Cluster HA Prophylaxis

A

Verapamil
Melatonin
Suboccipital inj of betamethasone
Lithium <0.3
Warfarin
Galcanezumab-gnlm
Steroids (prednisone 40-60mg/day taper over 3 weeks)

50
Q

Cluster HA Acute

A

Oxygen 6-12 L/min

SC triptan > intranasal in efficacy

51
Q

MS drug for pregnancy

A

Dimethyl fumarate (Tecfidera)

Natalizumab (Tysarbi) - possibly

Avoid all others in pregnancy

52
Q

MS therapies for spasticity

A
  1. baclofen, tizanidine
  2. dantrolene, diazepam
  3. intrathecal baclofen, gabapentin
  4. botox
53
Q

Dalfampirdine (Ampyra)

A

Treatment for walking impairment in MS – improves walking speed
10mg BID

54
Q

Dextromethorphan/quinidine

A

Treatment for pseudobulbar affect (espidoes of inappropriate laughing/crying)

Quinidine blocks first pass metabolism of DM, increasing DM concentrations

BCPS (34 decks)

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