Neurology Flashcards
What is used to treat ACUTE relapses of MS?
Corticosteroids
what are the AEs of corticosteroids
GI upset
insomnia
mood disturbace
which type of MS is disease-modifying therapy most effective for?
relapsing and remitting
Teriflunomide has a long 1/2 life, and takes ___ months to reach a steady state
3 months
Cholestyramine reduces the half life of which MS drug?
Teriflunomide
Which MS drug’s MOA is characterized by shifting cytokines from proinflammatory state, preventing immune cells from entering the CNS, reducing oxidative stress?
Dimethyl Fumarate
What are some AEs of Dimethyl Fumarate?
Flushing
itching
GI effects
Leukopenia/lymphopenia
of the MS medications, which 3 reduces relapse rates, but DO NOT slow MS progression?
Interferon Beta
Glatiramer Acetate
Teriflunomide
Which MS drug has a risk of Progressive Multifocal Leukoencephalopathy, and is only allowed if MS is rapidly advancing WITH failed all other therapies?
Natalizumab
T or F: MS symptoms increase in 2nd and 3rd trimester of pregnancy
FALSE - relapses decrease in 2nd and 3rd trimesters (but increase in first 3 months post-partum)
which 3 MS drugs to use in pregnancy
interferon beta
Glatiramer acetate
Natalizumab
a patient wants to conceive in 2 months; which MS meds must you D/C due to their long 1/2 lives?
Fingolimod
Teriflunomide
Which MS med is contraindicated in Men?
Teriflunomide
which MS meds are contraindicated in pregnancy?
Mitoxantrone
Teriflunomide
Symptomatic treatment is often used in MS. What is best to treat focal spasticity?
Botox
What is often used to treat systemic spasticity in patients with MS?
Baclofen
Tizanidine
What 2 medications are often used to treat fatigue in patients with MS?
Amantadine
Methylphenidate
what are the Neurotransmitters involved in seizures?
Glutamate
GABA
which anticonvulsant works as an autoinducer?
Carbamazepine
increases metabolism of itself and other drugs
this anticonvulsant has an interesting pharmacokinetic property; it is NOT capacity-limited, so it can process extra unbound drug better`
Valproate
(Valproic acid/Divalproex) - this means less severe dose related AEs
which 3 anticonvulsants are used in emergent situations?
Phenytoin
Phenobarbital
Valproic Acid
which seizure medication has a risk for Purple Glove Syndrome?
phenytoin
infusion causes tissue discoloration, edema, pain, necrosis
this anticonvulsant is capacity-limited; small changes in dose lead to LARGE changes in serum concentration
phenytoin
what is the major caution with phenobarbital?
respiratory depression possible!
which GABA enhancing anticonvulsant quickly terminates seizures
Benzodiazepines
which GABA enhancing anticonvulsant is also used to treat nerve pain?
Gabapentin, Pregabalin
What 2 anticonvulsants do not fit into either the Calcium/sodium channel or GABA receptor classification?
Levetiracetam
Topiramate
why don’t we want to D/C the 1st anticonvulsant medication too soon?
may cause breakthrough seizures; start new drug on low dose and increase gradually while slowly decreasing old drug.
May be able to D/C seizure medication after how long if they have a low risk of recurrence?
2-5 years
D/C over 1-3 months (slowly)
which 2 anticonvulsants are protein bound?
valproate and phenytoin
what is the preferred class of medication to stop seizure IMMEDIATELY (acute seizure)
Benzodiazepines
Midazolam, Lorazepam, Diazepam
Benzos are used emergently to STOP seizures, but what is used for the suppression of seizures?
Phenytoin
Phenobarbital
Valproate
(Infuse SLOWLY)
what 3 medications are used in REFRACTORY-STATUS epilepticus?
Midazolam (benzo)
Propofol
Phenobarbital - only if others fail
Which medication is NOT recommended in treating headaches in a patient also taking anticonvulsants(seizures):
Valproate
Lamotrigine
Topiramate
Lamotrigine - WORSENS headaches
other 2 are preferred for treating headaches
which antidepressant INCREASES seizure risk in a patient who is taking anticonvulsants
Bupropion
T or F: you can use Lamotrigine to treat headaches in patients who are prone to seizures, but you must avoid it in treating their depression
False - ok to use for depression, DO NOT use for headaches!
What treatment time frame must you follow before switching an Alzheimer’s patient to a different Cholinesterase inhibitor?
do a 3-6 month trial on MAXIMUM tolerated dose before switching
which cholinesterase inhibitor also inhibits butyryl cholinesterase?
Rivastigmine
of the ChE inhibitors for alzheimers, which may increase synaptic ACh the most?
Rivastigmine
how does Memantine (NMDA antagonist) work in the brain?
controls amount of calcium allowed into the nerve, regulating info storage (too much Calcium = disrupted info processing)
Which medications might help alzheimers patients with their aggression and agitation?
Buspirone
Trazadone
Selegiline
T or F: benzos are ok to use in Alzheimers patients for their anxiety
FALSE: increased risk of falls
pharmacological goal of treating parkinsons is to increase _____ concentrations in the substantia nigra
Dopamine
what do we most often start with when treating Parkinsons?
Levodopa/Carbidopa
T or F: the SNRIs (Venlafaxine, Desvenlafaxine, Duloxetine) all have short 1/2 lives
True - missed doses can cause withdrawal symptoms
Of the SSRIs, which has the longest 1/2 life?
Fluoxetine
Of the SSRIs, which has the shortest 1/2 life
Paroxetine
Of the SSRIs, which has risk of QT prolongation
Citalopram
Fluoxetine has a 1/2 life of ____ days
5-9
5-week washout before starting MAOI or 2 weeks before switching to another SSRI/SNRI
What is the MOA of SNRIs
serotonin and NE reuptake inhibition
SNRIs are contraindicated in what type of person?
Hepatic injury - alcohol abuse or chronic liver disease
What is Serotonin syndrome?
SSRI/SNRI + MAOI
SSRI/SNRI + SSRI/SNRI = confusion, restlessness, fever, hyperreflexia, diarrhea, shivering
MAO is an enzyme that is inhibited by MAOIs. What is the role of MAO in depression?
MAO breaks down 5-HT (serotonin, NE, DA).
Which class of depression medication must you be mindful of drug/food interactions, due to high risk of hypertensive crisis
MAOIs
avoid MAOI + sympathomimetic (pseudoephedrine, amphetamines, foods rich in tyramine)
Tricyclic antidepressant have many adverse effects. Which 2 give high risk for sedation and anticholinergic effects
Amitriptyline
Imipramine
If you Rx amitriptyline or imipramine (antidepressant), when should the patient take them?
at night - sedative effect, helps with sleep.
TCAs have a high risk of overdose, and significant additive effects with drugs that cause _______
sedation, hypotension, anticholinergic
Bupropion is what class of depression medication?
NE and DA reuptake inhibitor
When should patient take their daily dose of Bupropion?
Late afternoon - NOT AT NIGHT! Adverse effect is insomnia
Bupropion contraindication
CNS lesion
seizures
head trauma
bulimia
Of the 5-HT antagonists, which has higher risk of causing sedation and priapism
Trazodone
Prescribe this 5-HT antagonist for sleep, but add onto other antidepressants
Trazodone
Nefazodone isn’t used often for depression because of its risk for ______
hepatotoxicity
What are the partial 5-HT agonists?
Vortioxetine
Vilazodone
what are the adverse effects of Vortioxetine and Vilazodone that limits their use?
GI upset
St. Johns wort is commonly used to treat depression. What type does it work for and not work for?
works for mild depression
NOT effective for moderate-severe
Trazodone can treat depression but is mainly used for ____
sleep, due to its sedative effects
Which class of antidepressant is best for Depression + panic disorder?
SSRI
which SSRI is best used for treating depression + OCD
Fluvoxamine
physical symptoms of depression improve in ______ weeks while emotional symptoms take _____ weeks
1-2 weeks
2-4 weeks
(6-8 weeks for full effect)
T or F: If you add a 2nd antidepressant, add in the same class
False - add in a different class
Treatment of Acute phase of depression is how long?
6-12 weeks
the continuation phase of treating depression is how long
4-9 months
maintenance phase of treating depression is how long?
12 months - lifetime
what are the safest antidepressants in pregnancy?
Sertraline
Fluoxetine
Citalopram
TCAs
What are the best meds to treat geriatric patients with?
SSRI/SNRI
Bupropion
Mirtazepine
avoid this antidepressant in geriatric patients
TCAs
MAOIs
what are the only FDA-approved antidepressants for kids?
Fluoxetine
Escitalopram
Avoid this type of antidepressant in kids
Desipramine (TCA)
What is the drug of choice for General anxiety disorder, social anxiety disorder, panic disorder?
SSRIs (or SNRIs)
When starting a patient on SSRI for anxiety, what is the onset?
2-4 weeks
specifically which SSRI/SNRI meds are used in treating anxiety
Venlafaxine Duloxetine Paroxetine Escitalopram Sertraline
what is used in short term management of anxiety, when immediate relief is desired
Benzodiazepines
also used as adjunct to initiating anxiety meds
Are benzodiazepines effective in treating both somatic and psychic symptoms of anxiety?
yes
are benzodiazepines effective in treating anxiety AND depression?
not depression - only prn anxiety
Which of the following benzodiazepines is NOT short-lasting: Oxazepam Diazepam Lorazepam Temazepam Alprazolam
Diazepam (long lasting)
what are the 2 longer lasting benzodiazepines?
Clonazepam
Diazepam
which is the fastest-onset benzo for anxiety?
diazepam
which benzodiazepines bypass the CYP3A4 system and are to be used in hepatic dysfunction?
Oxazepam
Lorazepam
why should you never use benzos for long term anxiety treatment?
risk of addiction
how do you D/C benzos for anxiety if patient has been taking them for 2-6 months?
2-8 week taper
how do you D/C benzos for anxiety if patient has been taking them for 12 months?
2-4 month TAPER
what is an alternative treatment option for generalized anxiety disorder WITHOUT depression?
Buspirone
This medication is a good option for GAD, because it does not have abuse/addiction potential
Buspirone
what is the onset for buspirone, which is why benzos are still preferred treatment for acute anxiety?
2 weeks
less effective if patient previously treated with benzos
Verapamil Diltiazem Itraconazole Fluvoxamine Erythromycin all do WHAT to levels of buspirone?
INCREASE them
this is an alternative agent for treating anxiety, and is also an H1 blocker, not addictive
Hydroxyzine
T or F: hydroxyzine is effective for somatic and psychic symptoms of anxiety?
FALSE - only effective for SOMATIC symptoms
T or F: you can use hydroxyzine prn OR scheduledq
TRUE
what is first line therapy for preschoolers with ADHD?
behavioral therapy
what class of medication is 1st line in treating ADHD?
Stimulants
stimulants for ADHD are a controlled substance - what does this mean?
potential for abuse
what is the onset for stimulants to work?
30 minutes
how long to trial stimulants for ADHD before determining they are ineffective and switching?
trial for 3 months; try different stimulant.
Stimulant Contraindications
Glaucoma Severe HTN CV disease Hyperthyroidism previous drug abuse
Of all the adverse effects of stimulants, which 2 are a cause to D/C the med?
hallucinations
abnormal movements
Your patient was started on a stimulant 1 month ago. He reports experiencing hallucinations. What do you do?
D/C the med!
have patients take stimulant ______ min before meals to avoid drug-food interactions
30-60min - to avoid interactions
what “nonstimulants” can be used 2nd line for treatment of ADHD
Atomoxetine
Bupropion
Clonidine
Guanfacine
are nonstimulants controlled substances?
no - no abuse potential
this medication can be used as a nonstimulant for ADHD as well as an antidepressant - it is best chosen to treat a patient with ADHD + depression
Bupropion
onset 1-2 months
Bupropion CONTRAINDICATIONS
seizure
eating disorder
these 2 medications are nonstimulants; their MOA is alpha2 agonists
clonidine
guanfacine
these nonstimulants are less effective at treating ADHD, but are used as ADJUNCT to stimulants to control disruptive behavior
clonidine
guanfacine
you start your patient on a stimulant for is new diagnosis of ADHD. how often do you follow up?
every 2-4 weeks, and then every 3 months when stable
psychosis is caused by an excess in what neurotransmitter in the brain?
DA
which generation antipsychotics are preferred?
2nd - less likely to cause EPS, tardive dyskinesia
which SGA has greatest efficacy in treatment-resistant patients
clozapine
what 3 main adverse effects are associated with SGAs
weight gain
glucose/lipid abnormalities
metabolic syndrome
Which 1st line SGA has potential for the most adverse effects?
Risperidone (binds all the receptors)
-EPS, prolactin and lipid/glucose elevations, weight gain
which SGA is the active metabolite of Risperidone
Palperidone
Which SGA do you prescribe your patient with liver dysfunction?
Palperidone
which SGA is the worst culprit of metabolic syndrome in SGAs
Olanzapine
which SGA is the best choice to treat a patient who has ANXIETY AND DEPRESSION (as well as schizophrenia)
Quetiapine
Major adverse effect of Quetiapine
Prolongs QT interval
which 2 SGAs have a risk of QT prolongation
quetiapine
ziprasidone
Which SGA has the unique MOA, which addresses both hyper and hypo-DA levels in brain
Aripiprazole
what are the 3 most dangerous adverse effects of using first generation antipsychotics?
EPS
Tardive Dyskinesia
Neuroleptic malignant syndrome
you started a patient on a FGA, and 10 days later they report motor restlessness and muscle spasms. What is going on?
Extrapyramidal symptoms
what is EPS treated with?
IV Anticholinergics
T or F: Neuroleptic malignant syndrome is a life-threatening emergency
True
severe muscular rigidity, altered consciousness
this bad habit DECREASES concentration of clozapine and olanzapine
cigarette smoking
your patient has failed 2 antipsychotic trials with SGAs, and reports aggression and suicidality. Which treatment do you turn to?
Clozapine
Adverse effects that limit clozapine’s use
Seizures
myocarditis
Agranulocytosis
what do you need to monitor closely in your patients taking clozapine
hematology (risk of agranulocytosis)
what is an option for administration in patients who are high risk of nonadherence?
IM injections
what antipsychotics are recommended for treating kids?
SGA
avoid sedating, anticholinergic effects
this social activity is a risk factor for tardive dyskinesia
alcohol use
you are seeing a pregnant patient who has schizophrenia. What do you tell her regarding her medication and carrying a baby?
relapse is a greater risk for birth complications, STAY ON THE ANTIPSYCHOTIC
in an acutely psychotic patient, what do you administer?
intramuscular SGA
or
IM benzodiazepines
what do you NEVER treat bipolar patients with
antidepressants (may precipitate rapid cycling/manic episode)
what is the 1st line agent for classic bipolar?
Lithium
does Lithium have a wide or narrow therapeutic index?
NARROW - monitor!
goal is 0.6-1.4
commondrug interactions of Lithium
NSAIDs
Thiazides
ACE/ARB
what is lithium toxicity?
fluid loss from exersize, patient is vomiting, diarrhea, has deterioration in motor coordination and seizure. LIFE THREATENING!
at what serum level does lithium toxicity occur?
> 2 mEq/L
d/c lithium, may need gastric lavage
Lithium is not the best choice for someone with rapid cycling bipolar disorder. Instead, give this drug, which works like lithium but is better for rapid cycling
Valproic acid
T or F valproic acid has a narrow therapeutic index
false - WIDE
If your patient is taking Devalproex (valproic acid), what could happen if you also give them LAMOTRIGINE?
DANGEROUS RASH
which 2 mood disorder meds can contribute to agranulocytosis?
Clozapine
Carbamazepine
why might oxcarbazepine be favored over carbamazepine in treating bipolar?
no routine monitoring of serum concentration or hematology (anemia/agranulocytosis)
the risk of rash/SJS is HUGE when Lamotrigine and divalproex are combined. If you absolutely MUST use the 2, do you change the dose?
yes - lower Lamotrigine dose
can you use Lithium on a child?
yes, at lower doses.
which bipolar medication causes “floppy baby syndrome”
Lithium
what drug classes work for sleep aids?
benzodiazepine receptor agonists
Sedating antidepressants
What sedating antidepressant is the best option for elderly patients?
Doxepin
instead of stimulating pathways that cause sleepiness, this sleep aid turns OFF wakefulness
Suvorexant
only this sedating antidepressant has a sleep dose adequate to helping with depression (all others require lower dose for sleep)
Mirtazapine
What 2 meds reduce sleepiness? (Wake aids)
Modafinil
Armodafinil
when using Lithium, this organ needs to be monitored VERY closely
KIDNEY FUNCTION! decrease dose for renal impairment
what part of the brain is affected in Parkinsons?
Substantia nigra
lack of Dopamine neurons
A patient with Parkinsons has a depletion of DA, and it can cause motor fluctuations, akathisia, and dyskinesias. A drug that treats Parkinsons also does this. What is it?
Levodopa/carbidopa
although Levodopa/carbidopa is 1st line in treating PD, what is typically prescribed first to delay needing Levo/carb
DA agonists
Bromocriptine, Rotigotine, Pramipexole, Ropinirole, apomorphine
which classes of drugs are ONLY used in MILD Parkinsons disease?
Amantadine, Anticholinergics, MAO-B inhibitors, COMT inhibitors
benzo + olanzapine = ?
cardiorespiratory failure