Neuropsychiatric Flashcards
First 5 minutes of seizure
ABCs, vitals
Check Blood sugar
Get labs
First phase: 5-20 minutes
Benzos!
if unavailable try phenobarbital, diazepam rectal, nasal/buccal midazolam
Second Therapy phase: 20-40 minutes
no evidence based 1st choice
-Fosphenytoin IV
-Valproic Acid IV
-Levetiracetam IV (Keppra)
Third phase: 40-60 minutes
-Repeat any 2nd line therapy
-anesthetic dose of thiopental, midaz, pentobarbital or propfol
Anticonvulsants uses (approved and unapproved)
Seizures
Neuropathic pain
Mood stabilization
Migraines
Alcohol dependence
Calcium channel blockade
T-type channels located in the thalamus
Example of MOA SV2A drug
Keppra
Sodium Channel Blockers
Carbamazepine (Tegretol, Carbatrol)
Oxcarbazepine (Trileptal)
Eslicarbazepine (Aptiom)
Phenytoin/Fosphenytoin (Dilantin)
Lamotrigine (Lamictal)
Zonisamide (Zonegran)
Lacosamide (Vimpat)
Cenobamate (Xcopri)
What is the treatment of choice for Trigeminal neuralgia?
Carbamazepine (Tegratol)
Things to check when taking Carbamazepine, Oxcarbazepine, and Eslicarbazepine
Check Na+, platelets, and drug reactions!
Carbamazepine PK
CYP3A4 inducer + substrate
-Autoinducer
Common side effects for all seizures meds
dizziness, ataxia, confusion, slowing down of CNS
Advantage of Oxcarbazepine vs Carbamazepine
Created to eliminate the auto-induction of CBZ
Similar side effect profile
Less hyponatremia
Normal Phenytoin level
10-20
Fosphenytoin vs Phenytoin
Fosphenytoin = prodrug for IV administration
-Safer, better tolerated, faster infusion rates
ADRs for Phenytoin/Fosphenytoin
Gingival hyperplasia- long term side effect
Bone marrow hypoplasia
Arrhythmias, cardiovascular depression, hypotension
Ataxia
Nystagmus
Which drug has most approvals for different seizure types?
Phenytoin/Fosphenytoin
Recommended to increase at 50mg increments.
Phenytoin side effects if given during pregnancy
cleft palate, cleft lip, congenital heart disease, slowed growth rate, mental deficiency
Lamotrigine (Lamictal) and Depakote drug reaction
Stevens-Johnson syndrome!!!!!
Lamotrigine (Lamictal advantages
Less CNS toxicity and congenital malformations (has more excitatory symptoms tho)
-Be careful about when they are held and when they are started.
Zonisamide side effect
Renal stones in 1.5% of patients
rarely used
Lacosamide and Cenobamate facts
-Newer meds and VERY SAFE
-low side effect profile
-EXPENSIVE
Lacosamide and Cenobamate side effects
QT shortening, DRESS Rxn (strong rxn eosinophils skin,
CHECK EKGs!
Benzo that withdrawal can be FATAL
Clobazam (Onfi)
Benzos from longest duration of action and lipophilicity
Clobazam (Onfi)
Diazepam (Valium)
Clonazepam (Klonopin)
Lorazepam (Ativan)
Clorazepate (Tranxene)
Triazolam (Halcion)
Oxazepam (Serax)
Alprazolam (Xanax)
Midazolam (Versed)
Temazepam (Restoril)
Chlordiazepoxide (Librium)
Benzo with longest duration of action
Clonazepam (Klonopin)
Vigabatrin major side effect
Risk of PERMANENT vision loss
Gabapentin is more often used for _______ than _______
neuropathy rather than seizure control
Advantages of Gabapentin
-No PK drug interactions
-Very well tolerated
Risks of Gabapentin
gabapentinoids in combo with opiates and severe resp distress
Main use of Pregabalin
Main use in NEUROPATHY, may be used for seizures and anxiety
Pregabalin main ADRs
Difficulty concentrating
Risk for ataxia
Valproic Acid pregnancy risk
In utero exposure- lower IQ in children compared to other anti-epileptics (category D-X)
Valproic Acid ADRs
HYPERAMMONEMIA!
Hepatotoxicity
Thrombocytopenia
LFTs, platelets, Ammonia!
Labs to check with Valproic Acid
Check LFTs, platelets, ammonia
Most common Glutamate blocker?
Topiramate (Topamax)
Glutamate is excitatory
Rare monotherapy for seizures
Glutamate blockers
-Perampanel (Fycompa)
-Felbamate (Felbatol)
-Topiramate (Topamax)
“PFT”
Topiramate (Topamax) MOAs?
Multiple potential MOAs
-inhibitory sodium effects
-GABA
etc…
Topiramate ADRs
Psychomotor slowing
CNS side effects
Perampanel BB warning
-Serious or life threatening psychiatric and behavioral adverse effects
-Aggression, hostility, irritability, anger, homicidal ideation, THREATS
Common ADR of Perampanel
Dizziness (43%)
Levetiracetam (Keppra) MOA
related to synaptic vesicle protein 2A (SV2A) which appears to be important for the availability of Ca-dependent NT vesicles ready to release their content
Does Keppra have any significant drug interactions?
No!
-Basic seizure med side effects,
-accidental injury, convulsion
Med used for Absence Seizures
Ethosuximide
MOA: Depresses motor cortex calcium currents and elevated convulsive threshold
Triad of Overdose
Muscle relaxants, opiates, benzos
What kind of side effects does Cyclobenzaprine (Flexeril) have?
Anticholinergic Side Effects
Baclofen withdrawal symptoms with abrupt DC?
hallucinations, fever, agitation, tremor, tachycardia, seizure
How does Baclofen work?
Substance P inhibition into the spinal cord to reduce pain
Tizanidine MOA
Centrally acting alpha 2 agonist (precedex like)
Dantrolene MOA
Blocks ryanodine channel reduced Ca ++ release from SR
BB warning for Dantrolene
Dose dependent diarrhea and hepatotoxicity
> 800mg/day long term
Skeletal Muscle Relaxant general recommendation
Most should not be used long term due to significant ADRs and increased duration
Sedative Hypnotics (Z drugs)
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopiclone (Lunesta
BENZO-like
Amitriptyline (Elavil)
TCA that helps migraines and neuropathic pain
Tricyclic Antidepressant MOA and uses
MOA: Serotonin and Norepinephrine reuptake inhibition, Anticholinergic, 1A antiarrhythmic
Used for pain a lot
Tx for TCA overdose?
Bicarb d/t metabolic acidosis
TCA ADRs
Anticholinergic side effects
QT prolongation, arrhythmias
Most common antidepressant?
SSRIs
Citalopram (Celexa)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Fluvoxamine (Luvox)
SSRIs common side effects
-Hyponatremia (Check Na+ levels!)
-Thrombocytopenia
-Suicidality
-SEROTONIN SYNDROME
Paxil has ________ side effects.
Anticholinergic
Neuroleptic Malignant Syndrome cause
Dopamine Antagonists
NMS distinct features
HYPOreflexia
-normal pupils
-normal or decreased bowel sounds
-LEAD PIPE rigidity in ALL muscle groups
Onset 1-3 days
SS distinct features
-HYPERreflexia
-DILATED pupils
-Hyperactive bowel sounds
Faster onset < 12 hours
Check these with SSRIs
Vitals, Na+, platelets
SNRIs MOA
Serotonin and Norepinephrine reuptake inhibition
SNRIs ADRs
Hypertension (not related to SS)
Norepi adds excitatory side effects
Example of DNRI
Bupropion (Wellbutrin)
Meds used for people who have failed 4-5 SS/SNRIs
ZERO motivation
DNRIs
MOA: Dopamine and NE reuptake inhibitor
5HT2A antagonists drug names
Mirtazapine (Remeron) depressed, cant sleep no appetite
Nefazodone (Serzone)
Trazodone (Desyrel)
Vilazodone (Viibryd)
Think SLEEP
5HT2A antagonist ADRs
ADRs: Highly sedating, increased appetite, hepatoxicity
Nuedexta ADRs
(Dextromethorphan/Quinidine)
QT prolongation
Lithium action and MOA
Mood stabilizer (bipolar use)
MOA: Alters neuronal sodium transport
Lithium has ______ of ADRs!
LOTS! (CNS and CV toxicity)
Diabetes insipidus, polyuria, polydipsia
Long term renal damage
Toxicity
Weight gain
Nigrostriatal side effects
EPS, TD, parkinsons like mvmt
Mesocortical symptoms
Negative symptoms, cognitive and affective sx (depressive, hidden)
Most serious Antipsychotic ADRs
EPS, TD
BB warning for Antipsychotics
Dementia related death, agranulocytosis
What is Carbidopa used for ?
false dopamine (similar to beta-lactamase inhibitor use)
MAOB inhibitor MOA (“giline”)
Increase Dopamine availability via enzyme inhibition
Rasagiline (Azilect)
Selegiline (Eldepryl)
Acetylcholinesterase Inhibitors ADRs
Rest/digest side effects:
Bradycardia
Loose stools
OAB
Withdrawal of Meds warning
Never d/c a psych medication without reviewing risk of withdrawal
Only meds that can be started and stopped?
Dementia meds
Post-Op Delirium for older adults
-May be fatal, preventable in up to 40% of cases
-May be hypo or hyperactive or mixed presentation
-Almost 50% not reported (particularly hypoactive)
Post-op delirium prevention
Cognitive re-orientation, sleep hygiene, early mobility, nutrition/fluids, pain mgmt
Never use ______ for post-op delirium unless in the case of _______.
Benzos
ETOH withdrawal