Neuropsych medications Flashcards
What 3 things do you want to do during first 5 minutes of a seizure?
- ABC stabilization: check VS, O2, monitor
- Check BG: if <60 treat
- Get labs
What can be given to adults if BG is low to help with carbohydrate utilization?
Thiamine
What is the treatment of choice if a seizure lasts > 5min
Benzodiazepine
- Midazolam
- Lorazepam
- Diazepam
During the first phase of status epilepticus (5-20min) what other meds can be given if IV benzo isn’t available?
Phenobarbital
rectal Diazepam
nasal or buccal Midazolam
During the 2nd therapy phase (20-40 min) what is the evidence based first choice medication?
There is none. May use any of the following:
-Fosphenytoin
-Valproic acid
-Keppra
If above not available: phenobarbital if not already used
What is the treatment during the 3rd phase of status epilepticus?
Repeat any 2nd line therapy
Anesthetic doses of thiopental, midazolam, pentobarbital, or propofol
What are the 5 approved and unapproved indications for anticonvulsants?
Seizures Neuropathic pain Mood stabilization Migraines ETOH dependence
What are the 7 mechanisms of action of anticonvulsants?
- Sodium channel blockade
- Calcium Channel blockade
- GABA enhancers
- Glutamate blockers
- Carbonic Anhydrase Inhibitors
- Sex hormones (progesterone)
- Synaptic vesicle protein 2A (SV2S)
What are some examples of Na channel blockers?
Carbamazepine (Tegretrol, Carbatrol) Oxcarbazepine (Trileptal) Eslicarbazepine (Aptiom) Phenytoin/Fosphenytoin (Dilantin) Lamotrigine (Lamictal) Zonsamide (Zonegran) Lacosamine (Vimpat)
What Na channel blocker induces it’s own metabolism?
Carbamazepine
Does Carbamazepine have an active metabolite?
Yes
T/F: It is dangerous if you miss a dose of carbamazepine
FALSE
half-life is 5-26 hours
All of the “mazepines” have a risk of what electrolyte abnormality?
Hyponatremia
What Na channel blocker has a risk of thrombocytopenia, agranulocytosis, and aplastic anemia?
Carbamazepine
This medication “looks and smells like” Carbamazepine but is not as strong and has fewer interactions/
Oxcarbazepine
T/F: Oxcarbazepine does not have an active metabolite
FALSE
What Na channel blocker is a prodrug?
Eslicarbazepine
This newer Na channel blocker has more CNS side effects, but the risk of hyponatremia is low
Eslicarbazepine
What medication can treat the widest range of seizures?
phenytoin/fosphenytoin
What order of pharmacokinetics does phenytoin/fosphenytoin use?
non-linear (zero-order)
T/F: Phenytoin has active metabolites
FALSE
What Na channel blocker is a prodrug for parenteral administration?
Fosphenytoin
Phenytoin is a _________ anti-arrhythmic
1B
T/F: is it not safe to give phenytoin during pregnancy
TRUE
can cause cleft palate/lip, congenital heart disease, slowed growth rate, and mental deficiency
What is Lamotrigine most often used for?
Mood stabilizer
What 2 medications in combination can cause Steven-Johnson’s syndrome?
Lamictal and Depakote
This Na channel blocker is often used for absence seizures in children
zonisamide
*Can cause SE of oligohidrosis in children
This Na channel blocker is not used much, and is a pregnancy category C with ongoing pregnancy register
Lacosamide (Vimpat0
What 3 meds are GABA agonists?
Benzodiazepines
Phenobarbital
Primidone (Mysoline)
What Medication is a GABA reuptake inhibitor?
Tiagabine (Gabitril)
What type of GABA agent is Vigabatrin (Sabril)?
GABA transaminase inhibitor
What are 3 other GABA agents?
Gabapentin (Neurontin)
pregabalin (Lyrica)
Valproate (Depakote)
What is the DOC for seizure prevention?
Clobazam (Onfi)
What Benzos are often used as rescue meds bc they’re more lipophilic, have the fastest onset and longest DOA?
Diazepam (Valium)
Clonazepan (Klonapin)
Lorazepan (Ativan)
What prodrug that is metabolized to phenobarbital?
Primidone
What GABA agent has a risk of permanent vision loss?
Vigabtrin
What GABA agent given 30min pre-op can improve post-op pain and decrease opioid requirements?
Gabapentin
What is the “stronger version” of Neurontin?
Pregabalin - Lyrica
What drug is eliminated 90% unchanged in urine, absorption is slowed by food, and has not notable drug interactions?
Pregabalin
T/F: Valproic acid has an uncertain MOA
TRUE
may increase GABA synthesis, selective modulation of Na channels
In utero exposure to this anti-epileptic can lower IQ of children
Valproic acid
Name the 3 glutamate blockers
Felbamate (Felbatol)
Topiramate (Topamax)
Perampanel (Fycompa)
What glutamate blocker has a high risk of aplastic anemia and fatal hepatic failure?
Felbamate
*very limited use in the US
This glutamate blocker has multiple potential MOAs
Topiramate
What glutamate blocker is a noncompetitive agonist of AMPA?
Perampanel
What glutamate blocker has a BB warning of serious or life threatening psychiatric and behavioral adverse effects?
Perampanel
What are 3 meds with “other” MOAs?
Levetiracetam (Keppra)
Brivaracetam (Briviact)
Ezogabine (Potiga)
Levetiracetam’s MOA is possible related to ______________ which appears to be important for the availability of Ca-dependent NT vesicles ready to release their content
synaptic vesicle protein 2A (SV2A)
T/F: there are significant side effects and drug interaction with keppra
FALSE
What are the sedative hypnotics?
- Z-drugs: zolpidem (ambien), zaleplon (sonata), Eszopiclone (Lunesta)
- Ramelteon (rozerem)
- suvorexant (belsomra)
- Melatonin & Valerian root
Name the 6 groups of antidepressants
- Tricyclic antidepressants
- SSRIs
- SNRIs
- DNRIs
- 5HT2A antagonists
- Nuedexta
What are some examples of tricyclic antidepressants?
amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imiparmine (Tofranil) Nortriptyline (Pamelor)
What is the MOA for tricyclic antidepressants?
Serotonin and NE reuptake inhibition, anticholinergic, 1A antiarrhyhmic
T/F: TCAs can cause QT prolongation
TRUE
What do you administer if an OD of a TCA?
NaHCO3
due to metabolic acidosis
What are some examples of SSRIs?
Citalopram (Celexa) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Escitalopram (Lexapro) Fluvoxamine (Luvox)
Do you need to taper SSRIs when d/c-ing?
Yes
Which serotonin receptors are excitatory?
2, 3, 4, 6, 7
Which serotonin receptors are inhibitory?
1, 5
All serotonin receptors are g-coupled except which one?
3: Na/K ion channel
Where are 1:serotonin receptors located primarily?
Blood vessels and CNS
Where are 2:serotonin receptors located primarily?
Blood vessels, CNS, GI tract, platelets, PNS, smooth muscles
Where are 3:serotonin receptors located primarily?
CNS, GI tract, PNS
What is serotonin syndrome?
If block re-uptake, more serotonin available to act on receptors. When have excess serotonin can see rigidity, mass confusion, elevated temperatures, HTN
What are examples of SNRIs?
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Levomilnacipran (Fetzima)
What is the MOA of SNRIs?
Serotonin and NE reuptake inhibition
What type of symptoms will you see more with SNRIs than SSRIs?
Cardiovascular symptoms, like HTN
What is an example of a DNRI?
Bupropion (Wellbutrin)
What is the MOA of DNRI?
Dopamine and NE reuptake inhibitor
What are some 5HT2A antagonists?
Mirtazapine (Remeron)
Nerazodone (Serzone)
Trazodone (Desryl)
Vilazodone (Viibryd)
What are some side effects of 5HT2A antagonists?
Highly sedating, increased appetite, hepatoxicity
Nuedexta can cause what side effects?
Pseudobulbar effect: laugh/cry at inappropriate times
QT prolongation, lupus, thrombocytopenia
What is the MOA for lithium?
alters neuronal sodium transport
What are some SE of lithium?
Narrow therapeutic index
DI: polyruria, polydipsia
hypothyroidism
coma, seizures, sycope
What type medication should you avoid with lithium and why?
NSAIDS
Can cause lithium levels to increase
What are some examples of 1st generation antipsychotic meds?
Thorazine, Compazine, Haldol
What are some examples of 2nd generation antipsychotic meds?
Abilify, Clozaril, Zyprexa, Seroquel, geodon
What are the 4 pathways of dopamine in the CNS?
- Mesolimbic: positive symptoms of schizophrenia and psychosis
- Mesocortical: negative symptoms, cognitive and affective sx
- Nigrostriatal: EPS, TD
- Tuberohypophyseal: hyperprolactinemia
What is the MOA of antipsychotics?
S2/D2 blockade
What is the black box warning for antipsychotics?
Dementia related deaths
What are the 5 types of Parkinson’s meds?
Dopamine analogs Dopamine agonists anticholinergics MAOB inhibitors Other
What are some dopamine analogs?
Carbidopa/Levodopa (Sinemet)
Carbidopa/Levodopa/Entacopone (Stalevo)
What some side effects of dopamine analogs?
Basically SE of having too much dopamine CNS: hallucinations, psychosis, MDD, +II CV: hypotension, sycope Heme: blood dyscrasias, GIB GI: n/v, constipation
What are some dopamine agonists?
Pramipexole (Mirapex) Ropinirole (Requip) Rotigotine (Parlodel) Bromocriptine (Parlodel) Apomorphine (Apokyn)
This group of meds is the 2nd line for movement and Parkinson’s disorders
Anticholinergics
- Benztropine (Cogentin)
- Trihexyphenidyl (Artane)
What is the MOA of MAOB inhibitors?
Increase dopamine availability via enzyme inhibition
What are2 MAOB inhibitors?
Rasaligine (Azilect)
Selegiline (Eldepryl)
What are 2 “other” meds?
Amantadine (Symmetrel)
Nuplazid (Pimavanserin)
What are 2 classes of Alzheimer’s medications?
Acetylcholinesterase inhibitors -donepezil (Aricept) -Galantamine (Razadyne) -Rivastigmine (Exelon) NMDA receptor antagonists -Mamantine (Namenda)
What can anticholinergic meds do to NMBs?
Can potentiate succinylcholine
Reduce blockade of NMBs
T/F: You need to taper dementia meds prior to stopping.
FALSE
What is the difference between dementia and delirium?
Dementia: long-term cognitive decline
Delirium: rapid onset of confusion
T/F: According to JAMA, limiting the level of sedation provided no significant benefit in reducing the incident of post-op delirium
TRUE