Neuropsych Meds- AEDs Flashcards
1
Q
What should be done in the first five minutes of a seizure?
A
- ABC Stabilization
- Check BG
- Get labs and check for abnormalities
2
Q
In the first five minutes of a seizure, a blood sugar should be treated at or below ___mg/gl?
A
If <60mg/dl
3
Q
What is treatment for blood sugar <60mg/dl for a seizing patient?
A
Adult: Thiamine 100mg with 50ml D5W
Child>2yo: 2ml/kg D25 IV
Child<2yo: 4ml/kg D12.5 IV
4
Q
What is the first phase of status epilepticus?
A
5-20 mins long seizure
5
Q
What is second phase of status epilepticus?
A
20-40 mins long seizure
6
Q
What is third phase of status epilepticus?
A
40-60 mins long seizure
7
Q
What is first phase treatment for Status epilepticus?
A
- x1 Midazolam IM (>40kg=10mg, 13-40kg=5mg)
- Lorazepam IV (can repeat once) 0.1mg/kg (max 4mg)
- Diazepam IV (can repeat once) 0.15-0.2mg/kg (max 10mg)
8
Q
If midaz, loraz, or diazepam are not available, what can also be given for first phase?
A
- Phenobarb IV 15mg/kg x1
- Diazepam PR 0.2-0.5mg/kg (max 20mg)
- Nasal or buccal midazolam
9
Q
If status epilepticus has progressed to second phase, what can be used to treat?
A
- Fosphenytoin IV 20mg/kg (max 1500mg)
- Valproic Acid IV 40mg/kg (max 3000mg)
- Keppra IV 60mg/kg (max 4500mg)
10
Q
If fosphen, VPA, or keppra not available in phase 2, what can also be used?
A
Phenobarb IV 15mg/kg (if not previouslt used)
11
Q
T/F: In second phase status epilepticus, fosphenytoin is the drug of choice based on research evidence?
A
False; no evidence based first choice. Can use any of the choices available (keppra, VPA, fosphenytoin)
12
Q
If status epilepticus has progressed to third phase, what can be used to treat?
A
No clear evidence, but choices include:
- Repeat any second line therapy
- Anesthetic doses of thiopental, midazolam, pentobarbital, or propofol
13
Q
T/F: If anticonvulsant medication is held or stopped, there is only a risk of seizures if patient has or has previously had epilepsy?
A
False; even if patient has not had a seizure and that medication is not specifically prescribed for seizure. there is still a risk
14
Q
What are the 7 different MOA for anticonvulsant therapy?
A
- Sodium channel blockade
- Calcium channel blockade
- GABA enhancers
- Glutamate blockers
- Carbonic anhydrase inhibitors
- Sex hormones
- Synaptic vesicle protein 2A (SV2A)
15
Q
What are examples of Sodium channel blockers?
A
- Carbamazapine (Tegretol,Carbatrol)
- Oxcarbazepine (Trileptal)
- Eslicarbazepine (Aptiom)
- Phenytoin/fosphen (Dilantin)
- Lamotrigine (Lamictal)
- Zonisamide (Zonegran)
- Lacosamide (Vimpat)
16
Q
What are the four uses for Carbamazepine?
A
- Partial and generalized seizures (less often for seizures)
- Mood stabilizer
- Neuropathic pain
- Trigeminal neuralgia (1st line therapy)
17
Q
T/F: Carbamazepine is most frequently prescribed for seizures compared to its other uses?
A
False
18
Q
What is unique about the pharmacokinetics of Carbamazepine?
A
- Induces its own metabolism
- CYP3A4 inducer and substrate
- 75-85% protein bound
- Has active metabolite
19
Q
If carbamazepine induces its own metabolism, how does that affect its administration?
A
Will have increasingly higher dosage requirement with time
20
Q
Side effects of carbamazapine?
A
- Dizzness, ataxia, diplopia, nausea.
- Aplastic anemia, agranulocytosis, thrombocytopenia
- Stevens Johnson
- Increased LFTs
- Hyponatremia
21
Q
Which side effect is seen in nearly all patients taking carbamazapine?
A
Hyponatremia
22
Q
How is oxcarbazepine (Trileptal) different than carbamazapine?
A
- Not self inducing
- Better tolerated
- Fewer drug interactions
- Slightly less side effect risk
23
Q
How is eslicarbazepine (Aptiom) different than carbamazapine?
A
- Its a prodrug broken down to S-licarbazepine
- Needs renal dose adjustment
- Even less side effects when compared to oxcarbazepine/carbamazapine
24
Q
What anticonvulsant has non-linear pharmacokinetics?
A
Phenytoin/fosphenytoin (Dilantin)
25
What does non-linear pharmacokinetics mean?
When you increase the dose of the medication, the serum levels do not go up in a normal linear line. They can go up exponentially and are different for each patient. Its zero order, so the eliminates a certain amount every hr, independent of drug concentration in the body
26
The non-linear pharmacokinetics of Dilantin can pose a specific problem when?
When changing from IV to PO or PO to IV
27
What are two adverse side effects that can be seen with long term dilantin use?
1. Gingival hyperplasia
| 2. Osteoporosis/Bone marrow hypoplasia
28
What are side effects of dilantin?
1. Arrythmias, CV depression, HoTN
2. Ataxia, nystagmus, N/V
3. Blood dyscrasias
4. Vit K and folate deficiency
5. Osteoporosis, rash
29
T/F: Dilantin is one of the few drugs that is recommended in pregnant women?
False; can cause cleft palate, cleft lip, CHD, slowed growth rate, mental deficiency
30
How is lamotrigine (Lamictal) similar to carbamazapine pharmacokinetically?
It can autoinduce, but only at high doses
31
If not tapered correctly, lamotrigine (Lamictal) has a high risk of causing ________ when used in combo with VPA
Stevens Johnson reaction
32
Does lamotrigine (Lamictal) have active metabolites?
No
33
What are the two most common CNS related symptoms seen with lamotrigine (Lamictal)?
Psychosis and insomnia
so risk of post-op delirium, agitation with Lamictal
34
What drug does lamotrigine (Lamictal) have a an interaction with?
Valproic Acid. Causes steven-johnson syndrome
35
What drug does zonisamide have an interaction with?
None. No drug interactions
36
What side effect does zonisamide cause specifically in children?
Oligohidrosis
37
What two medications is it common to see "psycho-motor disconnect" (slowed down thought process)?
Zonisamide and Topiramate
aka "mental slowing"
38
Side effects of zonisamide (zonegran)?
1. Dizziness, ataxia, HA, confusion, speech abnormalities, mental slowing,
2. Anorexia or weight gain
3. Irritability, tremor
4. Renal stones in 1.5% pts
6. Rash, skin reactions
39
Half lives of Phenytoin, lamotrigine, zonisamide, lacosimide?
Phenytoin= variable 7-42hrs
Lamotrigine=24-41hrs
Zonisamide=60hrs
Lacosamide=13hrs
40
Pros/Cons Lacosamide (Vimpat)?
Pros:
Minimal protein binding
*No induction/inhibition CYP*
Nice side effect profile
Cons:
Expensive
Pregnancy Category C
41
What are the four categories of GABA Agents?
1. GABA Agonists
2. GABA Reuptake Inhibitors
3. GABA Transaminase Inhibitors
4. GABA "Other" (Not agonists, but enhance the GABA activity
42
Of all the benzos, what has the most significant withdrawal risk?
Clobazam (Onfi)
its only use is actually for seizures, not anxiety like the other benzo's
43
What drug is metabolized to phenobarbital and what is it used for?
Primidone is a prodrug that is metabolized to phenobarbital and it is seen with patients with musculo-skeletal disorders.
44
What drug classes/drugs fall under GABA Agonists?
1. Benzos
2. Phenobarbital
3. Primidone (Mysoline)
45
What drug classes/drugs fall under GABA Reuptake Inhibitors
Tiagabine (Gabitril)
46
What drug classes/drugs fall under GABA Transaminase Inhibitors?
Vigabatrin (Sabril)
47
What drug classes/drugs fall under GABA "Others"?
1. Gabapentin (Neurontin)
2. Pregabalin (Lyrica)
3. Valproate (Depakote)
48
What is REMS?
Medication Monitoring system. Special pharmacies are the only distributors and the patient needs to be monitored very closely
49
What is gabapentin mostly used for?
More often used for neuropathy than seizure control
50
Pharmacokinetics of Gabapentin?
1. Not protein bound
2. Not metabolized
3. No induction
4. Excreted completely unchanged in kidneys
5. No PK Drug interactions
51
Pre-operative Gabapentin does what two things?
1. Reduces opiate requirements
| 2. Increased post op sedation
52
Side effects of Gabapentin?
Overall very, very mild side effects- rash, neutropenia, somnolence, dizziness, ataxia, fatigue, nystagmus, diplopia, HA, tremor, N/V (all only really seen at high doses)
53
What is pregabalin (Lyrica)'s most common use?
Diabetic neuropathy
considered to be "Neurontin like", but has more sedation and ataxia compared to gabapentin
54
What are two other (less common) uses for Pregabalin (Lyrica)?
Seizures and anxiety
55
MOA of Pregabalin(Lyrica)?
GABA Analogue, binds alpha-2 and delta receptor sites which reduces release of excitatory neurotransmittors via Ca++ currents
56
Pharmacokinetic considerations for pregabalin(Lyrica)?
1. Half life 6 hours
2. Food reduces absorption
3. No plasma protein binding
4, 90% unchanged in urine
5. No notable PK drug interactions
57
Pregabaline (Lyrica) ADRs?
1. *Dizziness*, drowsiness, blurred vision, difficulty concentrating
2. Dry mouth
3. Edema, rare angioedema
4. Weight gain
58
Post-operative considerations for Pregabalin (Lyrica)?
Post-op delirium and confusion risk
59
T/F: There are several different forms of Valproic Acid (VPA), and they all have different effects and side effects to remember?
False; many different forms, but all have same SE/effects
60
How would a low albumin effect VPA?
It is 85-90% protein bound and low protein could have higher risk of toxicity
This can occur in trauma, burn, liver dz, malnutrition, hypoalbuminemia
61
Where is VPA metabolized?
Liver
62
If VPA at toxic levels d/t overdose, what should be done?
Stop the medication and within 2.5 days, levels will fall to safe levels
b/c half life is about 16hrs
63
Three main SEs to watch for with VPA?
1. Hepatoxicity (highest risk in children, accompanied with rare but fatal pancreatitis)
2. Thrombocytopenia (risk of bleeding)
3. Hyperammonemia (may present as liver failure/very confused patient)
Emily harped on all 3 of these
64
T/F: Though VPA is associated with drug interactions, it is safe for pregnant women?
False; it is associated with drug interactions through inhibition of oxidation and glucoronidation pathways, but it is NOT recommended for parturients (cat D-X)
VPA can cause lower IQ kids
65
Why is felbamate rarely used in the US?
High risk of aplastic anemia and fatal hepatic failure
66
Three main uses of topiramate (Topamax)?
1. Alcohol withdrawal
2. Migraine Prophylaxis
3. Seizures
67
MOA of Topiramate (Topamax)?
1. Sodium Channel blocker
2. GABA enhancement of unknown mechanism
3. AMPA Inhibition (part of NMDA, so inhibits glutamate)
4. Weak carbonic anhydrase inhibitor
(Basically, global potential suppression. It "kind of hits all the different sites", per Emily"
68
T/F: Topiramate (Topamax) has many drug interactions, but compared to many other drugs, it has a good side effect profile?
False; It has not drug interactions
69
What is the side effect profile of Perampanel?
1. BB Warning for life threatening psych/behavioral effects
2. Dizziness (43%-Most common)
high risk of SE, so it's not used a lot. If on it, risk of post-op agitation and delirium
70
MOA of levetiracetam (Keppra)?
1. Possibly related to synaptic vesicle protein 2A (SV2A)= important for the Ca++ dependent neurotransmitter vesicles ready to release their content
2. Reduces bicuculline induced hyperexcitability
3. Inhibits Ca++ release from IP3-sensitive stores
71
Does keppra play nicely with other drugs?
Yes, yes it does
72
Levetiracetam ADRs?
1. Somnolence, asthenia, dizziness, HA, convulsion, cognitive impairment, pain
2. Accidental injury
3. Infection (URI, pharyngitis, flu-like symptoms)
73
Which GABA Analog has significant withdrawal risk?
Baclofen
74
MOA Baclofen?
1. Presynaptic Hyperpolarization
A. Reduced Ca++ influx
B. Reduced glutamate release
C. Decreased alpha-motor neuron activity
2. Post-synaptic activation
A. Increased K+
B. Hyperpolarization
3. Substance P Inhibition in spinal cord to reduce pain (Emily mentioned this one as the big one)
75
What are withdrawal symptoms of baclofen?
1. Hallucinations
2. Fever
3. Agitation
4. Tremor - significant
5. Tachycardia
6. Seizures
76
MOA of Tizanidine?
Centrally acting Alpha 2 Agonist (may potentiate glycine)
77
Tizanidine ADRs?
1. Dry Mouth
2. Sedation
(mostly look like anticholinergic effects)
78
MOA of Dantrolene?
Blocks ryanodine channel----reduces Ca++ release from sarcoplasmic reticulum
It's similar to phenytoin
79
What is BB warning for dantrolene?
Dose dependent diarrhea and hepatotoxicity
80
At what dose does Dantrolene have black box warning symptoms?
>800mg/day with long term use
81
Primary three ADRs of skeletal muscle relaxants?
1. Significant sedation
2. Confusion
3. Lethargy
4. Dizziness
Worry about oversedation when they come in for surgery
82
What are signs of sedative hypnotics withdrawal?
1. Confusion
| 2. Insomnia
83
Examples of sedative hypnotics:
1. "Z-Drugs and like benzo-lites": zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta)
2. Ramelteon (Rozerem)
3. Suvorexant (Belsomra)
4. Melatonin and Velerian root
84
What does Nuedexta treat?
Falls under antidepressant, but is used for pseudo-bulbar affect
85
What class of antidepressants is the oldest group?
Tricyclic
86
MOA of tricyclic antidepressants?
Serotonin and NE reuptake inhibition, anticholinergic, and 1A antiarrhythmic properties
Dosed at bedtime
87
What are the two major ADRs of tricyclic antidepressants?
1. Anticholinergic side effects
| 2. Cardiovascular- QT prolongation and arrhythmias
88
Overdose treatment of tricyclic overdose consists of what?
1. Admin NaHCO3 d/t metabolic acidosis
| 2. Supportive therapy
89
What drug class does Emily consider the primary medication for depression?
SSRIs
90
Examples of SSRIs?
1. citalopram (Celexa)
2. fluoxetine (Prozac)
3. paroxetine (Paxil)
4. sertraline (Zoloft)
5. escitalopram (Lexapro)
6. fluvoxamine (Luvox)
91
T/F: All SSRIs work the same way, but have slightly different affinity for specific serotonin receptors
True
92
What are the G-Couple 5-HT receptors?
1, 2, 4, 5, 6, 7
93
What are Na/K Ion channel 5-HT receptors?
3
94
What are Excitatory 5-HT receptors?
2, 3, 4, 6, 7
(4,6,7 Increase cAMP)
(2- Increase IP3 and DAG2)
(3-Depolarizes Plasma membrane)
95
What are Inhibitory 5-HT receptors?
1, 5
96
What do inhibitory 5HT receptors do?
Decrease cAMP
97
What does 5HT-3 receptor do?
CNS, GI Tract, PNS
(GI Motility, emesis, nausea)
ex. zofran
98
What does 5HT-1 receptor do?
Blood vessels and CNS
(addiction, aggression, anxiety, appetite, heart rate, vasoconstriction, emesis, memory, mood, nausea, pain, sexual function, thermoregulation)
99
What does 5HT-2 receptor do?
Blood vessels, CNS, GI tract, Platelets, PNS, Smooth Muscles
(Addiction, anxiety, appetite, cognition, learning memory, mood, perception, sexual function, platelet aggregation, perception)
100
Side effects of SSRIs?
1. *Hyponatremia* - very high rates
2. *Thrombocytopenia*
3. Suicidality (gives people a higher level of energy, so now they have the energy to carry out suicide plan
4. Arrhythmias
5. Serotonin Syndrome - like MH, but no rigidity. hyper reflexes instead
6. N/V/D and weight fluctuations
101
MOA of SNRIs?
Serotonin and NE reuptake inhibition
102
Examples of SNRIs?
1. duloxetine (Cymbalta)
2. venlafaxine (Effexor)
3. desvenlafaxine (Pristiq)
4. levomilnacipran (Fetzima)
103
How does thiamine help with low blood glucose during seizures?
Helps to utilize carbohydrates, esp in the nerves
104
What class of meds are 1st line treatment for status epileptics?
Benzodiazepines
2nd is phenobarbitals
105
2 off-label uses of Topamax
Migraines and alcohol dependence
106
Seizure meds whose MOA is calcium channel blockade work or _ - type channels in the thalamus
T-type
107
What electrolyte is mediated by GABA enhancers?
Cl-
108
What three seizure meds are highly protein bound?
Carbamazepine (75-85%)
phenytoin (70-95%)
VPA (Depakote) (85-95%)
109
Why is it important to adjust phenytoin in small baby doses?
Has a narrow TI (10-20), so easy to become toxic
doubling a dose can quadruple drug levels d/t non-linear, zero-order PK's
110
T/F Dilantin has no active metabolite
True
111
Dilantin is a ___ anti arrhythmic
1b
112
T/F There is a risk of hyponatremia with Lamictal
FALSE. no hyponatremia risk
113
Is there a high or low fetal risk with Lamictal?
Low. Not completely gone, but a lot less compared to dilantin
114
What is the safest sodium channel blocking seizure med available?
lacosamide (Vimpat)
115
What is important to know about vigabatrin?
needs REMS dispensing bc of risk of permanent vision loss
116
T/F
Gabapentin is not protein bound, not metabolized, and excreted completely unchanged by kidneys
True
117
What med has more sedation and ataxia complications, lyrica or neurontin?
Lyrica
118
VPA is associated with drug interactions through inhibition of _____ and _____ pathways
Oxidation
glucoronidation
HAS NO CYP INTERACTIONS
119
What electrolyte plays a role in Keppra's MOA?
Ca+
120
T/F
| Muscle relaxants have no withdrawal risk
FALSE
some are very severe like Flexeril and Tizanidine (Zanaflex)
Most Significant is Baclofen
121
Can you go into withdrawal from sleep meds?
Yes, especially the z-ones (zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta)
122
Examples of TCA's
```
Amitriptyline (Elavil) – used for HA’s, neuropathic pain
Clomipramine (Anafranil)
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
```
123
What is a major adverse reaction from SNRI's? Why does it occur?
HTN. b/c you block NE reuptake, so there is more readily available.
124
What are other adverse effects of SNRI's?
```
Serotonin syndrome
Hepatotoxicity
Hyponatremia
Insomnia, abnormal dreams, somnolence
N/V/D
Weight loss
Tremor, agitation
```
125
What med is an example of a DNRI? What is it's MOA?
Bupropion (Wellbutrin)
Dopamine and NE reuptake inhibitor, hence it is a
Excitatory-type antidepressant
126
2 approved uses Bupropion (Wellbutrin)
smoking cessation and antidepressant
can also be used to supplement ADHD meds, and approved for PTSD
127
ADR's of Bupropion (Wellbutrin)
Causes a fight/flight scenarios, so...
```
Insomnia
Agitation, Anxiety
Tachycardia, HTN
Weight loss
promotes seizures
```
128
Who would not be a good candidate for wellbutrin?
someone who already has anxiety b/c it is very stimulating
129
Per Emily, What is a the big difference b/w SSRI's and SNRI's?
SNRI's have a greater risk of HTN
SSRI's - have to worry about sodium and PLT's
130
Examples of 5HT2A Antagonists?
Mirtazepine (Remeron)
Nefazodone (Serzone)
Trazodone (Desryl)
Vilazodone (Viibryd)
131
ADR's of 5HT2A Antagonists?
HIGHLY SEDATING (only dosed at bedtime)
Increased appetite
Hepatotoxicity
Think of fall risk in the elderly
132
What two drugs make up Nuedexta? Who would be on Nuedexta?
Dextromethorphan/Quinidine
Dx: Pseudobulbar affect from strokes or TBI's
133
MOA of Nuedexta
Quinidine increases DM levels through enzyme inhibition. DM may inhibit NMDA receptors, sigma 1 agonist.
Quinidine levels are so low that it doesn't really affect HR
134
Why don't you get cough suppressant effects form Nuedexta?
DM has to be metabolized to get cough suppression
135
What is the main concern if a patient is on Nuedexta?
Drug interactions because quinidine is a POTENT 2D6 inhibitor
136
ADR's of Nuedexta
```
QT prolongation
lupus
GI (Most common)
edema
anemia
thrombocytopenia
```
137
What class of medication is lithium?
Mood stabilizer
it is NOT a antidepressant, antipsychotic
138
MOA of lithium
Alters neuronal sodium transport (Tricks the body into believing it is sodium)
Both have 1+ charge, so replaces sodium in neuronal firing. But because it is not sodium, it does not complete first part of action potential, hence slows down action potential
139
ADR's of lithium
```
Diabetes insipidus, polyuria, polydipsia
Coma, Seizures, Tremors (at toxic levels)
Arrhythmias, syncope
Hypothyroidism
weight gain
N/V/D
Cognitive impairment, fatigue
Skin damage, acne, alopecia
```
140
What are common complications of long term lithium?
Kidney damage, lot of CNS issues
141
Doe lithium have a narrow or wide therapeutic window?
Narrow, very prone to being affected by fluid shifts and electrolyte abnormalities (b/c since its similar to Na+, it follows water).
Even more so if they have kidney damage
142
What happens if you give NSAIDS to someone on lithium?
pain levels will go up
143
T/F
The more dopamine you have, the more agitated you are
True
The less you have, you get more parkinson-like movements
144
Which 2nd gen antipsychotic has anticholinergic effects?
Seroquel (Highly sedating)
145
Which 2nd gen antipsychotic has alpha2 blockade?
Geodon
This one can cause orthostatic hypotension
146
What is important to know about 1st gen antipsychotics?
More sedating, higher risk of EPS/tardative dyskinesia, possible more CV effects
147
EPS, parkinson-like movement and tardative dyskinesia from antipsychotics come from the blockade of _____
dopamine
can be permanent
148
what are the metabolic side effects fo antipsychotics
hyperglycemia
weight gain
HLD
149
What antipsychotic has the highest risk of QT prolongation?
Haldol
geodon and zyprexa (2nd gen's) have it as well to some degree
150
What is the blackbox warning for all antipsychotics?
Dementia-related death
151
T/F
patients who are started on antipsychotics have a higher risk of death
True
usually from CVA's, sometimes from MI's
152
What are two important things to consider when starting someone on antipsychotics
Only start if pt is at risk of harming self or others
Use lowest dose for shortest amount of time
153
Which antipsychotic has risk of agranulocytosis?
Clozapine (Clozaril)
dispensed through REMS because of this.
Want to check ANC (Absolute Neutrophil Count) with CBC to monitor for agranulocytosis
154
How many dopaminergic pathways are there in the body?
| What are they?
4
Mesolimbic
Mesocentric
Nigrostriatal
Tuberohypophyseal
155
Which dopaminergic pathway is associated with hyperprolactinemia?
Tuberohypophyseal
will see gynocomastia
156
Which dopaminergic pathway is assoc. with EPD, TD, and parkinson movement when blocked?
Nigostriatal
157
Which dopaminergic pathway is assoc. with positive symptoms of schizophrenia and psychosis?
Mesolimbic
158
Which dopaminergic pathway is assoc. with negative symptoms?
Mesocentric
159
Who should you never administer antipsychotics to?
Delirium-associated dementia
only as an absolute last resort
160
What the big difference between antipsychotics and parkinson meds
Trying to block dopamine with antipsychotics
Trying to increase dopamine with parkinson meds
161
4 classes of parkinson meds
Dopamine analogs
Dopamine agonists
Anticholinergics
MAOB inhibitors
162
What two meds are dopamine analogs?
Carbidopa/Levodopa (Sinemet)
Carbidopa/Levodopa/Entacapone (Stalevo)
Levodopa = dopamine precursor
Carbidopa = false dopamine, "suicide inhibitor"
Entacapone (Comtan) = COMT inhibitor
all increase the amount of dopamine
163
ADR and SE's of dopamine analogs?
CNS: Hallucinations, *psychosis*, MDD, +SI
CV: *Hypotension*, syncope
Heme: Blood dyscrasias, GIB
GI: N/V, constipation
we get side effects of too much dopamine, so agitation, psychosis, drops in BP
so will see post-op agitation with low BP
164
What meds are dopamine agonists?
```
Pramipexole (Mirapex)
Ropinirole (Requip) - can get nightmares, insomnia
Rotigotine (Neupro Patch)
Bromocriptine (Parlodel)
Apomorphine (Apokyn)
```
165
MOA of dopamine agonists
simply activate dopamine receptors. Don't look like dopamine, so can't be broken by MAO and COMT
used for restless leg syndromes
166
SE's of dopamine agonists
same as dopamine analogs
167
What meds are anticholinergic parkinson meds?
Benztropine (Cogentin)
| Trihexyphenidyl (Artane)
168
What meds are MAOB inhibitors?
Rasaligine (Azilect)
| Selegiline (Eldepryl)
169
MOA of MAOB inhibitors?
Increase DA availability via enzyme inhibition
170
What med has no dopamine activity and is given specifically for a diagnosis of parkinson's with psychosis?
Nuplazid (Pimavanserin)
171
MOA of Nuplazid (Pimavanserin)
Inverse agonist and antagonist at 5HT2A and 5HT2C receptors
172
ADR's of Nuplazid (Pimavanserin)
QT prolongation - risk of torsades
173
What are two non-specific class meds for parkinson's?
Amantadine (Symmetrel)
| Nuplazid (Pimavanserin)
174
T/F
There is no risk of withdrawal with alzheimer meds
True
175
Type of alzheimer meds
Acetylcholinesterase Inhibitors:
Donepezil (Aricept)
Galantamine (Razadyne)
Rivastigmine (Exelon)
NMDA receptor antagonists:
Memantine (Namenda)
176
Side effects acetylcholinesterase inhibitors
"rest and digest" SE's bc there is more ACh floating around to activate the PNS, so...
Bradycardia
Loose stools
Overactive bladder
usually taken at night
177
2 major drug interactions with acetylcholinesterase inhibitors
can potentiate succinylcholine and reduce the blockade of NDNMB's
178
What is the only side effect with Namenda?
Dizziness
179
Post-op delirium may be fatal, preventable in up to __% of cases and __% of cases are not reported
40%
| 50% (because they are hypoactive)
180
T/F
Post op delirium may be hypo or hyperactive or mixed presentation
True
181
Difference between delirium and dementia
Delirium – rapid, acute
| Dementia – long term, slow
182
Preferred treatment for prevention/treatment of post-op delirium
non-pharmacological
also make sure they aren't having increased pain bc that can increase neurotransmitters
183
T/F
changes in the depth of anesthesia reduce the risk of post-op delirium
FALSE
does not reduce the risk
184
What class of meds absolutely increase the chance of post-op delirium?
BZD's
185
What is the only time BZD's may be appropriate to treat post-op delirium?
If its related to ETOH withdrawal
186
What is important to know about the STRIDE trial?
limiting the level of sedation provided no significant benefit in reducing incident delirium.
187
Should antipsychotics be used to treat post-op delirium
Only if at risk to harm self or others. Use lowest dose for shortest duration possible
188
Two important things to know about prophylactic haldol from studies
Px low dose po haloperidol did not reduce delirium incidence in acutely hospitalized older patients.
Px Haldol does not reduce mortality in critically ill adults at high risk of delirium
189
Which two 2nd gen antipsychotics have a higher risk of QT prolongation?
Geodon and Zyprexa
