Neurology Flashcards

Question

Acetylcholinesterase Inhibitors Administrations: 1. Donepezil should be dosed QHS or QAM? 2. Slower titration (Q4-6 weeks) may decrease _______ side effects. If treatment interrupted for ___ or more days, retitrate from starting dose. 3. Adlarity is a patch that is dosed Q______ and should be stored in _______. Rotate application sites and do NOT use same site within ____ days. Where to apply patch?

Answer 1

1. *QHS due to nausea (but QAM if experiencing insomnia)* 2. GI; 3 days 3. week; *refrigerator* (take patch out prior to get to room temp and apply within 24 hours of taking out of fridge); *14; upper or lower back (preferred) or upper buttocks or upper outer thigh*

Answer 2

4.* Exelon (rivastigmine); QD; upper or lower back (preferred) or upper arm or chest; 14 -Apply to back to avoid pt trying to remove* 2. True 3 True 4 *10mg; Namzaric (memantine 7mg/donepezil 10mg QHS)*

Answer 3

Brand: *Namenda (with donepezil: Namzaric)* -NaMenDA = NMDA MOA: *N-methyl-D-aspartate (NMDA) receptor inhibitor which prevents gluatamate, an excitatory neutrotransmitter from binding to cause overstimulation and neuronal death* ROA: PO Administration: -*ER capsule, Namzaric: do NOT crush or chew; capsules can be sprinkled on applesaurce and swallowed immediately* -Oral solution: use provided dosing syringe AVEs: *generally well tolerated -Dizziness, confusion, HA, constipation* Warnings: caution w/ drugs or conditions that increase urine pH, reducing clearance of memantine (sodium bicarbonate, acetazolamide, severe UTI)

Answer 4

Temporary conditions: fever (common in children), infection, alcohol withdrawl, hypoglycemia, electrolyte abnormalities Drugs that lower seizure threshold: -Analgesics: opioids (especially tramadol, meperidine)* -Anti-infectives: quinolones, carbapanems*, cephalosporins*, PCNs*, meflorquine -Psychiatric medications: bupropion, antipsychotics (especially clozapine), lithium*, TCAs* *=high dose and/or renal impairment increases risk

Answer 5

Focal seizures: *starts on one side of brain, but can spread to other side; further classified as either focal aware (no loss of conscioussness) or focal seizure w/ impaired awareness* Generalized seizures: *start on both sides of the brain; pt losses consciousness or is unaware during seizure* Motor symptoms: sustained rhythmical jerking movements (clonic), limp or weak muscles (atonic), muscle twitching (myoclonus), and rigid or tense muscles (tonic) Non-motor symptoms: changes in sensation, emotions, thinking, or cognition

Answer 6

Tonic-clonic seizures: uncrontrolled jerking movements Absense seizures: *generalized seizures with non-motor symptoms* Status ellipticus: *seizure that lasts 5 minutes or longer*

Answer 7

1. Stabilization Phase -Stabilize circulation, airway, and breathing -Time seizure and start ECG -Check ASM (antiseizure medication) levels and electrolytes -*If BG low, give dextrose* 2. Initial TX Phase: *if seizure continues, give IV lorazepam, IM midazolam, or IV diazepam -Alternatives: rectal diazepam or intranasal or buccal midazolam* 3. Secondary TX Phase: *if seizure continues, give non-BZD anticonvulsant: IV fosphenytoin, valproic acid, or levetiracetam -Alternative: IV phenobarbital* 4. Refractory TX Phase: no clear evidence to guide therapy; repeat second line or midazolam, phenobarbital, or propofol

Answer 8

1. *Anticonvulsant - do NOT stop abruptly (could lead to increased seizures) -Broad spectrum (treat both focal and generalized seizures): lamotrigine, levetiracetam, topiramate, valproic acid -Narrow spectrum (treat focal seizures): carbamazepine, phenytoin -Absence seizures: ethosuximide* 2. Adjunctive - medical marijuana (cannibas), ketogenic diet, vagal nerve stimulation, or surgical intervention Epidiolex (cannabidiol = CBD):* does NOT contain tetrahydrocannabinol (THC)* -Consider additive CNS effects (somnolence, euphoria, anxiety, paranoia) and DDIs -Typically for seizures associated w/ Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex *Ketogenic diet: high fats, normal protein, and low carbohydrates (usually 4:1 ratio of fat:combined protein and carbohydrates)* -Forces body to breakdown fatty acids into ketone bodies as energy source which can pass into brain and replace glucose (ketosis) -Consider vitamin supplementation -Ex. Eggs, leafy vegetables, pork, poultry, beef, nuts, seeds, olive oil, coconut oil, seafood, cheese

Answer 9

GABA: gamma-aminobutyric acid, inhibitory neutrotransmitter --> goal to enhance Glutamate: excitatory neutrotransmitter --> goal to reduce Na channels: reduce to decrease neuronal firing rate Ca channels: reduce to slow down or stops transmission of electrical signals

Answer 10

-CNS depression -Cognitive impairment, fall risk -Suicidal risk -Bone loss as soon as two years after starting (fracture risk) -Many: rash (including SJS/TENs) or DRESS

Answer 11

-ALL: vitamin D and calcium -Child of womenbearing age: folate -Valproic acid: possibly carnitine -Lamotrigine and valproic acid, if alopecia develops: biotin, selenium, and zinc

Answer 12

-Highly protein bound: clobazam, phenytoin, valproic acid -Enzyme inducers: carbamazepine, oxcarbazepine, phenytoin, fosphenytoin, phenobarbital, primidone -Enzyme inhibitor: valproate

Answer 13

Brand: Lamictal, Lamictal ODT, Lamictal Starter Kit, Lamictal XR MOA: inhibits Na channels and decreases glutamate ROA: PO TX: broad spectrum anticonvulsant (focal and generalized seizures), bipolar disorder

Answer 14

AVEs: *alopecia (supplement biotin, zinc, and selenium)*, N/V, somnolence, rash, tremor, ataxia, impaired coordination, dizziness, diplopia, blurred vision Warnings: *multiorgan hypersensitivity rxns (DRESS),* aseptic meningitis, blood dscrasias, cardiac rhythm abnormalities, serious rare immune system rxns (hemophagocytic lymphohistiocytosis = HLH) BBW: *serious skin rxns (SJS, TENs) --> D/C at any sign (reason for titration)* Monitoring: rash, fever

Answer 15

1. 25mg PO QD for week 1 and 2 2. If D/C for 5 or more half lives (>6 days for most patients) 3. Starter Kits: select based on DDIs (UGT can alter serum concentrations) -Blue = lower dose --> take if on valproic acid (B for "below") -Orange = normal dose --> take if NO interacting medications -Green = higher dose --> take if pt taking enzyme inducer (ex. carbamazepine, phenytoin, phenobarbital, primidone) and NOT taking valproic acid (G for "grow higher") **Oral estrogen-containing contraceptives may lower lamotrigine as well

Answer 16

Brand: Keppra, Keppra XR MOA: inhibits vesicle fusion via binding to SV2A proteins ROA: PO, IV -IV to PO ratio: 1:1 TX: broad-spectrum anticonvuslant (focal and generalized seizures) -Preferred in pediatrics (easy formulations, pregnancy, and for DDIs

Answer 17

AVEs: somnolence, dizziness, weakness, asthenia Warnings: *psychiatric rxns (psychotic symptoms, somnolence, fatigue*, aggression, anxiety, suicidal behavior), anaphylaxis, angioedema, coordination difficulties, severe skin rxns, multiorgan hypersensitivity rxns (DRESS), hematologic abnormalties (anemias mainly), loss of seizure control during pregnancy DDIs: *NO significant DDIs*

Answer 18

Brand: *Topamax*, Topamax Sprinkle, Trokendi XR, Qudexy XR MOA: *inhibits Na channels* ROA: PO Administration: Topamax Sprinkle: swallow whole or sprinkle on small amount of soft food (do NOT chew, swallow immediately) TX: *broad-spectrum anticonvulsant (focal and generalized seizures), migraine prophylaxis*

Answer 19

AVEs: *somnolence*, dizziness, psychomotor slowing, *difficulty w/ memory/concentratoin/attention*, weight loss, anorexia, paresthesia Warnings: hyperchloremic non-anion gap *metabolic acidosis, oligohidrosis* (reduced perspiration/hyperthermia mostly in children and from inhibition of carbonic anhydrase), *nephrolithiasis*, acute myopia and secondary angle-*glaucoma, hyperammonemia* (alone or w/ valproic acid), *visual problems* (reversible), *fetal harm* CI: -Trokendi XR: alcohol use 6 hours before or after dose -Qudexy XR: pt w/ metabolic acidosis taking metformin DDIs: weak CYP2C19 inhibitor and inducer of CYP3A4 -Phenytoin. carbamazepine, valproic acid, and lamotrigine decrease topiramate levels -Can decrease efficacy of oral contraceptions (especiall doses >/=200mg/day) --> *NON-hormonal contraception recommended* -Can decrease INR in pt on warfarin Monitoring: electrolytes (*especially bicarbonate*), renal fxn, hydration status, *eye exam (IOP)*

Answer 20

Divalproex: valproic acid derivative Valproate: refers to any formulation of valproic acid, valproate sodium, or divalproex Brand (divalproex): *Depakote, Depakote ER, Depakote Sprinkle* MOA: *inhibits Na channels and increases GABA, an inhibitory neutransmitter* ROA: PO, IV TX: *broad-spectrum anticonvulsant (focal and generalized seizures), bipolar disorder, migraine prophylaxis* Therapeutic range: *(50-100 mcg/mL (total level)*

Answer 21

AVEs: *alopecia (supplement w/ biotin, selenium, zinc), N/V, weight changes (gain* > loss), HA, anorexia, abdominal pain, dizziness, *somnolence, tremor*, edema, diplopia, blurred vision Warnings: *hyperammonia (TX: carnitine in symptomatic adults or lactulose*), hypothermia, dose-related *thrombocytopenia* (increased bleeding risk), multiorgan hypersensitivity rxns *(DRESS)* CI: hepatic disease, urea cycle disorder, prophylaxis of migraine in pregnancy, certain mitochondrial disorders if <2 yo BBW: *hepatic failure* (usually during first 6 months, children <2 yo and pts w/ mitochondrial disorders), *fetal harm (neural tube defects and decreased IQ scores), pancreatitis* Monitoring: *LFTS (baseline and frequently in first 6 months), CBC w/ differential (especially PLTs)*, serum levels, serum ammonia

Answer 22

Valproate = weak inhibitor of CYP2C9 and UGT, minor substrate of 2C19 and 2E1, and can displace drugs from protein-binding sites Increases levels of: *lamotrigine (USE lower starting dose)*, phenobarbital, phenytoin, *warfarin*, and zidovudine Salicylates: displace valproate from albumin, increasing levels Drugs that decrease valproate levels: carbapenems, estrogen-containing contraceptives Topiramate: use can lead to hyperammonemia w/ or w/o encephalopathy

Answer 23

Brand: *Vimpat* MOA: not fully known, may decrease Na channels ROA: PO, injection TX: *narrow-spectrum anticonvulsant (focal seizures)* AVEs: dizziness, HA, diplpia, blurred vision, ataxia, tremor. euphoria (CV substance) Warnings: *prolongs PR interval (increased arrhythmias risk), multiorgan hypersensitivity rxn (DRESS),* syncope, dizziness, ataxia Monitoring: ECG (baseline and steady state) in at-risk pts DDIs: caution w/ other drugs that prolong PR interval (beta-blockers, CCBs, digoxin) --> AV block and bradycardia risk

Answer 24

Brand: *Tegretol, Tegretol XR* MOA: *inhibits Na channels* ROA: PO TX: *narrow spectrum anticonvulsant (focal seizures), bipolar disorder, trigeminal neuralgia* Therapeutic range:* 4-12 mcg/mL*

Answer 25

AVEs: dizziness, drowsiness, ataxia, N/V, pruritus, photosensitivity, blurred vision, rash, increased LFTs, alopecia, renal impairment Warnings: hypersensitivity rxn (increased in pt w/ HLA-A*3101 allele), multiorgan hypersensitivity rxns (DRESS), *hyponatureamia (SIADH - increases antidiuretic hormone*), hypothyroidism, increasd IOP, cardiac conduction abnormalities, liver damage, *fetal harm* CI: *myelosupression*, hypersensitivity to TCAs, use of MAOIs within 14 days, use with nefazodone or NNRTIs (substrates of CYP3A4) *BBW:* -Serious skin rxns (SJS/TEN) --> HLA-B*1502 allele testing required for Asian descent prior to starting -Aplastic anemia and agranulocytosis --> D/C if significant myleosuppression occurs

Answer 26

Monitoring: *CBC w/ differential* (including PLTs) prior to start during, LFTs, rash, eye exam, thyroid function tests, *serum Na*, renal fxn DDIs: *autoinducer that decreases levels of its own and others* -Strong inducer of CYP3A4, P-gp, and others --> can decrease levels of many drugs including aripiprazole, levothyroxine, warfarin, hormonla contractives (*recommended to use NON-hormonal conctraceptive)* -Major CYP3A4 substrate: caution with strong inhibitors/inducers -Do NOT use w/ nefazodone or NNRTIs -Suspension should NOT be taken with other liquids (precipitates)

Answer 27

1. Structurally similar (CI if hypersensitivity to eslicarbazapine) 2. *Consider testing HLA-B*1502 allele in Asian descent* 3. Similar AVEs: skin rxns, hyponatremia -No agranulocytosis warning 4. DDIs: *NOT an autoinducer, weak CYP3A4 inhibitor and CYP2C19 inhibitor (non-hormonal contraceptive also recommended, caution with strong CYP3A4 inducers)* Brand: Trilleptal

Answer 28

Brand: Dilantin, Dilantin Infatabs MOA: inhibits Na channels ROA: PO, IV TX: narrow-spectrum anticonvulsant (focal seizures) Therapeutic range: -Total level: 10-20mcg/mL -Free level: 1-2 mcg/mL IV to PO ratio: 1:1

Answer 29

AVEs: -Chronic: *gingival hyperplasia, heptatoxicity*, hair growth, morbilliform rash (measles-like rash), peripheral neuropathy, increased BG, metallic taste, connective tissue hyperplasis -Toxicity: *nystagmus, ataxia, diplopia*/blurred visoin, slurred speech, dizziness, somnolence, lethargy, confusion, delirium Warnings: -*Extravastion that can lead to purple glove syndrome (edema, pain, and bluish discoloration of skin that may lead to tissue necrosis)* -Avoid in pt w/ *positive HLA-B*1502 test* and had severe rxn w/ carbamazepine -Multiorgan hypersenstiivty rxns (DRESS), fetal harm, bradycardia, skin rxns (SJS/TEN), blood dyscarsias, cardiac arrest, hepatic and renal impairment, hypothyroidism CI: previous hepatotoxicity from phenytoin *BBW:* infusion-related hypotension and cardiac arrhythmias -*phenytoin IV administration rate should NOT exceed 50mg/min* -fosphenytoin IV (Cerebyx; prodrug of phenytoin): should *NOT exceed 150mg PE/minute or 2mg PE/kg/min* *Monitoring:* serum concentrations, LFTs, CBC w/ differential -IV: continuous cardiac ECG, BP, and HR; respiratory fxn

Answer 30

1. DDIs: phenytoin and fosphenytoin -Strong inducers of several enzymes which will decrease concentraton of many drugs including anticonvulsants, contraceptives, and warfarin --> use non-hormonal contraceptive -High protein binding and can displace other highly protein-bound drugs 2. Administration -IV phenytoin: do NOT exceed 50mg/min; requires a filter; dilute in NS (stable for 4 hrs, do NOT refrigerate) -NG phenytoin: enteral feedings decrease absorption, hold feedings 1-2 hours before and after administration -IV fosphenytoin: do NOT exceed 150mg PE/min, lower risk of purple glove syndrome than phenytoin 3. Phenytoin correction = [ total phenytoin measured / (0.2 x albumin - 0.1) ] -Use when albumin <3.5 g/dL and CrCl >/=10mL/min 4. 1 mg PE (Phenytoin Equivalent) = 1.5mg fosphenytoin

Answer 31

Brand: Sezaby MOA:* enhances GABA, an inhibitory neutrotransmitter* ROA: PO, injection TX: *narrow-spectrum anticonvulsant (focal seizures)* Therapeutic range: *20-40 mcg/mL (adults)*

Answer 32

AVEs: *physiological dependence, tolerance, residual sedation* (hangover effect), somnolence, cognitive impairment, dizziness, ataxia, depression, folate deficiency Warnings: *potential for drug dependency, respiratory depression, fetal harm*, paradoxical rxns (hyperactive or aggressive behavior in acute pain or pediatrics), hypotension (IV), serious skin rxns (SJS/TEN) CI: severe hepatic impairment, dyspnea or airway obstruction, previous addiction to sedative-hypnotics, intrarterial administration Monitoring: LFTs, CBC w/ differential *DDIs*: phenobarbital and prodrug (primidone) are strong inducers of several enzymes including CYP3A4 and P-gp; can significantly decrease hormonal contraceptive (use non-hormonal contraceptives)

Answer 33

Carbamazepine, oxcarbazepine, eslicarbazepine: hyponatremia, rash, enzyme induction -Eslicarbazepine: active metabolite is oxcarbazepine Gabapentin, pregabalin: weight gain, peripheral edema, mild euphoria -Primarily for neuropathy pain Topiramate, zonisamide: weight loss, metabolic acidosis, nephrolithiasis, oligohidrosis/hyperthermia (in children)

Answer 34

Brand: *Zarontin* MOA: *inhibits T-type Ca channels* ROA: PO TX: *absence seizures* AVEs: N/V, abdmonial pain, weight loss, hiccups, dizziness, somnolence Warnings: *serious skin rxns (SJS/TEN), blood dyscrasias*, multiorgan hypersenstivitiy rxn (DRESS) Monitoring: LFTs, CBC w/ differential, urinalysis, PLTs, rash, trough serum concentration

Answer 35

1. Felbamate BBW: aplastic anemia 2. Fenfluramine BBW: valvular heart disease, pulmonary HTN (REMS) 3. Vigabatrin BBW: permanent vision loss 4. Zonisamide CI: hypersensitivity to sulfonamides

Answer 36

-Teratogenic: clonazepam, phenobarbital, primidone, phenytoin, fosphenytoin, carbamazepine (neural tube defects), valproic acid (neural tube defects) -Preferred (least risk): levetiracetam, lamotrigine -Many anticonvulsants reduce efficacy of hormonal contraceptives --> use non-hormonal -Folate supplementation for women of childbearing age -Anticonvulsant levels can decline during pregnancy (may need dose increase) and increase during postpartum (may need dose decrease)

Answer 37

-Concerns of CNS depression and cognitive difficulties (children can outrow epilpesy --> continue to monitor need for medication) -Use easier formulations (lamotrigine ODT or chewable tablets, levetiracetam ODT or oral solution) -Topiramate, zonisamide: can cause reduced sweating (hypohidrosis) --> limit sun exposure to avoid hyperthermia -Lamotrigine-induced rash fatality occurs more commonly in children

Answer 38

Diazepam rectal gel - contains two rectal syringes prefilled 1. Hold barrel of syringe in one hand w/ cap facing downward and dose window visible 2. Use other hand to grasp the cap firmly and turn to adjust dose 3. Confirm the correct dose shows in window. Hold the locking ring at the bottom of the syringe barrel and push upward on both sides of the ring. Once locked, the green band should say "READY", and the syringe cannot be unlocked. 4. Repeat steps for the second syringe