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NAPLEX BABY > Oncology & Psych/Neurological > Flashcards

Oncology & Psych/Neurological Flashcards

1
Q

what is carcinoma?

A

cancer that starts in skin or in the tissues that line or cover internal organs

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2
Q

What is Luekemia?

A

cancer of the leukocytes (WBCs): leukemia is referred to as blood cancer

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3
Q

What is Lymphoma?

A

cancer of the lymphatic system

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4
Q

What is Multiple myeloma?

A

a type of bone marrow cancer

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5
Q

What is sarcoma?

A

cancer in connective tissue (tissue that connects, supports, binds or separates other tissues), including fat, muscle, blood vessels and bone. Osteosarcoma is a type of bone cancer

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6
Q

Skin cancers: Basel cell/squamous cell & melanoma

A

BC/SC: common, unlinkey to metastasize, simple to remove surgically or with topical tx
M: skin cancer that forms in the melanocytes (the skin cells that produce the pigment (melanin) that colors skin] the least prevalent type of skin cancer (2%) but the most deadly

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7
Q

Staging of cancer: 0-4, TNM staging

A

-used to describes the cancer, how large the tumor is and if it has metastasized
TNM:
–T = tumor size and extent
– N=spread of the cancer to lymph nodes
–M = whether the cancer has metastasized

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8
Q

7 Signs of cancer: CAUTION

A

C: change in bowel or bladder
A: a sore that does not heal
U: unusual bleeding or discharge
T: thickening or lump in breast/elsewhere
I: indigestion or difficulty swallowing
O: obvious change in wart or mole
N: nagging cough or hoarseness

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9
Q

How can low dose aspirin help in cancer prevention/protection?

A

-rec for prevention of coloractal cancer in those who are 50-59 y/o, have ACSVD risk > 10%, have > 10 yr life expectancy and are at low risk of bleeding

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10
Q

Consideration for highly toxic drugs: Bleomycin

A

-lifetime cumulative dose of 400 units
–> causes pulmonary toxicity

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11
Q

Consideration for highly toxic drugs: Doxorubicin

A

-lifetime cumulative dose: 450-550 mg/m2
–> causes cardiotoxicity
-anthracycline durg GIVE DEXRAZOXANE PROPH

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12
Q

Consideration for highly toxic drugs: Cisplatin

A

-dose per cycle not to exceed 100 mg/m2
–> nephrotoxicity
*give Amifostine (Ethyol) for prohp to reduce risk
-ensure hydration

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13
Q

Consideration for highly toxic drugs: Vincristine

A

-single dose “capped” at 2 mg
–> neuropathy

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14
Q

Cancer tx drugs that commonly cause hepatotoxicity

A

-antiandrogens [ bicalutamide, flutamide, nilutamide –> used mainly for prostate cancer]
-metothrexate

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15
Q

What 2 cancer tx drugs cause hemorrhagic cystitis?

A

-ifosafamide (all doses)
-Cyclophosphamide (higher doses > 1 gram/m2)
** give mesna (mesnex) w/ Ifosafamide (and sometimes cyclo) to reduce risk & ensure hydration–> push fluids with mannitol to cause osmotic diuresis

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16
Q

What cancer medications cause neuropathy?

A

-vinca alkaloids (vincristine, vinblastine, vinorelbine)
–> limite dose of vincristine to 2 mg /dose
-platinums (cisplatin, oxaplatin)
–> oxa: avoid cold temps and cold drinks

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17
Q

What cancer meds cause thromboembolic risk?

A

-aromatase inhibitors ( anastrozole, letrozole)
-SERMs (tamoxifen, raloxifene) – breast cancer drugs

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18
Q

Chemo man toxicity: Methotrexate

A

-mouth sores (mucrositis), 5 FU can also cause
–> give leucivorin to help reduce toxicity

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19
Q

Chemo man toxicity: CNS toxicity

A

-caused by nitrosureas: carmustine and lomuestine

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20
Q

Chemo man toxicity: nephrotoxicity and ototoxicity

A

-Cisplatin (dose < 100 mg/m2 per cycle!!)
-Carboplatin
–> give fluids and mannitol!
–> MUST DISPENSE AMIFOSTINE with both meds for protection

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21
Q

Chemo man toxicity: pulmonary fibrosis

A

-bleomycin (life time cap of 400 units!)
-busulfan

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22
Q

Chemo man toxicity: cardiotoxicity

A

-Doxorubicin: lifetime dose capped at 450-550 mg/m2
-Daunorubicin
–> MUST GIVE DEXRAZOXAME!

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23
Q

Chemo man toxicity: hemorrhagic cystitis (“I Pee”)

A

Ifosfamide: more toxic
Cyclophosphamide
–> give fluids (NS and mannitol) and MESNA TO PROTECT THE BLADDER!

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24
Q

Chemo man toxicity: Peripheral neuropathy

A

-both hands and feet (VT)
-Vinca alkaloids: vincistine (max single dose 2 mg), vinloblastine, vinorelbine)
-Taxanes: pacitaxel, docetaxel

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25
Q

Chemo man toxicity: Bone marrow suppression

A

ALL EXCEPT:**
-vincristine (bad nausea, neuropathy, capped at 2 mg/dose)
-bleomycin (pulm fibrosis, capped at lifetime 400 un
-monoclonal abs
-TKIs
**give colonoy stimulating growth factors (filgrastim)*

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26
Q

Chemo man toxicity: acute diarrhea

A

-irinotecan –> “ I ran to the can”
–> stop this with adding atropine to IV bag (stops acute cholinergic crisis)
-sent pts home with loperamide

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27
Q

chemo adjunctant medications: Doxxorubicin

A

-dexrazoxane (Zinecard)
-dexrazone (totect) –> antidote

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28
Q

chemo adjunctant medications: Fluorouracil

A

-leucovorin or levoleucovorin –> give with to enhance efficacy

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29
Q

chemo adjunctant medications: Fluorouracil or capecitabine

A

-give uridine triacetate as an antidote

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30
Q

chemo adjunctant medications: Methotrexate

A

-leucovorin or levoleucovorin: give proph to protect cells from toxicity
-glucarpidase: used as an antidote it acute renal failure to increase med clearance

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31
Q

difference stages of neutropenia

A

–> the lower the WBC count, the higher risk of infection
-neutropenia: < 1000
-severe neutropenia: < 500
-profound neutropenia: < 100
ANC= [WBC * (% neutrophils + % bands) / 100] *

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32
Q

CSF: Filgrastim (Neupogen), Pegfilgrastin (Neulasta)

A

-F: given daily
-P: given weekly with chemo (should give at least 14 days before next doc chemo cycle)
SE: fever, bone pain, arthalgias, myalgias, rash
–> store in fridge

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33
Q

Febrile neutropenia temp requirements

A

-oral temp > 38.3 (101) x 1 reading
-oral temp > 30.0 (100.4) sustained for > 1 hr
–> ANC < 500 or ANC < 1000 and is expected to dec to < 500 during the next 48 hrs

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34
Q

Febrile neutropenia tx: low risk

A

-expected ANC < 100 for < 7 days, no comorbidities
–> oral anti-pseudomonal abx: cipro, levofloxacin PLUS amox/clauv (for gram + coverage) or clindamycin (if allergic to penicillin)

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35
Q

Febrile neutropenia: high risk

A

-expected ANC < 100 for > 7 days, presence of comoborbities, evidence of renal or hepatic impairement
–> IV anti-pseudomonal beta-lactams: cefepime, ceftazidime, meropenem, imipenem/cilastatin or pip/tazo

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36
Q

Anemia tx in cancer pts

A

-ESA agents can shorten survival and inc tumor progression = NOT rec in pts for curative care, only pallitive
–> initiate when Hgb < 20**
-use the lowest dose needed to avoid RBC transfusion
-need to make sure serum ferritin, TSAT and TIBC are normal or ESA wont work

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37
Q

Risk factors for chemo-induced nausea and vomiting

A
  • female gender
    -< 50 y/o
    -dehydration
    -hx of motion sickness and N/V
    –> admin. antiemetics 30 mins before chemo
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38
Q

drugs used for low emetic risk

A

-1 drug (any except NK1-RA)
5ht3-RA (dolasetron, granisetron, ondansetron)
dexamethasone
prochlorperazine
metoclopramide

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39
Q

drugs used for moderate emetic risk

A

-2-3 drugs
NK-1RA + 5HT3-RA + dexamethasone [netupitant/palonosertron or fosnetupitant/palonosertron + dexamethasone]
5HT-RA + dexamethasone
Palonosteron + olanzapine + dexamethasone

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40
Q

drugs for high emetic risk

A

-3-4 drugs
*olanzapine + netupitant/palonosertron or fosnetupitant/palonosertron + dexamethasone
-palonosteron + olanzapine + dexamethasone
-netupitant/palonosetrone or fosnetupitant/palonosertron + dexamethasone

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41
Q

NK-1 RA: aprepitant (Emend), Fosaprepitant,

A

-inhibit substance P, augmenting the antiemetic activity of 5HT-3 receptor antagonists

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42
Q

5HT-3 receptor antagonists: odansertron (zofran), granisetron (Sancuso), Palonosteron

A

CI: do not use with apomorphine
Warnings: inc in QT interval, serotonin syndrome
SE: headache, constipation

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43
Q

Dexamethasone (for chemo N/V)

A

CI: systemic fungal infections
SE: inc appetite, fluid retention, insomnia
–> higher doses inc BP and blood glucose

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44
Q

Dopamine Receptor Antagonists (Prochloperazine, promethazine, metoclopramide, olanzapine, haloperidol)

A

BBWs:
-prochlorperazine: inc mortalilty in elderly
-promethazine: do not use in children < 2 y/o, do not give via intra-arterial or SC
-metoclopramide: tardive dyskinesia, dec dose with renal impairment
-haldol: QT prolongation
Warnings: symptoms of parkinsons disease can be exacerbated
SE: sedation, lethargy, EPS, seizures

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45
Q

Chemo induced diarrhea (meds)

A

-Irinotecan: causes cholinergic excess, including diarrhea with abdominal cramping
-Atropine –> can be given to PREVENT acute diarrhea
-Pilocarpine: causes salivation, used for xerostomia (dry mouth) caused by some cancer drugs- also used for lacrimation (tears) and is used for dry eyes

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46
Q

Hand-foot syndrome management

A

-occurs with tx with capectabine, flourouracil- due to small amounts of chemo dripping into the capillaries of the hands and feet
-limit daily activity to reduce friction and heat exposure to hands and feet
-emollients (aquaphor, udder cream and bag blam) are used to retain moisture, topical steroids and pain medications can also be used
-cooling hands and feet with cold compress may provide temp. relief of pain and tenderness

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47
Q

Treatment of tumor lysis syndrome

A

S&S: acute hyperkalemia, hypocalcemia, and hyperuricemia = AKI
-allopurinol 400-800 mg/day
-if get a skin rash from allo, can use febuxostat
-Rasburicase is used for initial tx in pts with high risk (WBC > 100,000)
-both should be given IV w/ normal saline

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48
Q

Hypercalcemia of malignancy

A

-1st line: IV bisphosponate (pamidrone, zoledroonic acid)
–> severe cases: calcitonin can be added (for up to 48 hrs)
-can also use denosumab (Xgeva)

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49
Q

HER2 overexpression & TX

A

-HER2/neu oncogene promotes breast tumor growth: overexpression amplifies cancer cell growth and survival
* Trastuzumab (Herceptin): binds to the HER2 receptor, preventing dimerization –> Mbas can trigger severe reaction- premedicate with (dexameth (steroid), diphenhydramine (antihistamine) & acetaminophen)

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50
Q

SERMS: Tamoxifen (soltamox), raloxifene (Evistal)

A

-used for premenopausal ER+ breast cancer
BBW: inc risk of uterine or endometrial cancer, thromboembolic events
CI: do not use with warfarin, hx of DVT/PE (use venlafaxine to treat hot flashes if needed)
SE: hot falshes, vaginal bleeding, dec bone density
–> TERATOGENIC,

Raloxifene (IM): used in women for breast cancer prevention and osteoporosis prevention/tx

**contin for at least 5 yrs

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51
Q

Aromatase inhibitor: Anastrozole (Arimdex), Letrozole (femara)

A

-blocks conversion of androgens to estrogen –> used in post menopausal women
-higher risk of osteoporosis and. CVD
Ci: pregnancy
SE: hot flashes, myalgias (painful muscles)

**contin for at least 5 yrs

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52
Q

common drugs used to treat metastatic breast cancer

A

-capecitabine
-carboplatin
-cyclophhosphamide
-docetaxel
-paclitaxel
-doxorubicin
-methotrexate

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53
Q

GnRH agonists (Leuprolide (Lupron), goserelin (Zoladex)

A

-LHRH hormones agonsits; reduce testosterone through a negative feedback mechanism, causing an initial surge in testosterone, followed by gradual reduction
–> dec bone density; supp w/ calcium/vit D
–> cause tumor flare: prevent w/ concurrent use of an antiandrogen (bicalutamide) for several weeks
SE: hot flashes, impotence, gynecomastia, bone pain, QT prolongation

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54
Q

Antiandrogen, first generation: Bicalutamide (Casodex)

A

-competitively inhibit testosterone from binding to prostate cancer cells–> used in combination with a GnRH agonist
CI: do not use in females
SE: hot flaashes, gynecomastia

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55
Q

What chemo drugs are cell cycle INDEPENDENT (AAP: all awesome pharmacists)?

A

–> tumor killing not dependent on the phase of the cell cycle
-Alkylating agents (cyclophosphamide, Ifosfamide)
-Anthracyclines (doxorubicin, Mitoxantrone)
-Plantinum Compounds: Cisplantin, Caroplatin)

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56
Q

What chemo drugs are S-phase (DNA replication) dependent? (AT)

A

-Antimetabolites (methotrexate, pemetrexed, Fluorouracil, Capecitabine)
-Topoisomerase I Inhibitors (Irinotecan, Topotecan)

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57
Q

BSA formula (Mosteller Equation)

A

BSA = st[(ht cm * wt kg) / 3600]
in –> cm = in * 2.54
lb –> kg = lb/2.2
Male norm = 1.9
Female norm = 1.6

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58
Q

Alkylating Agents (cell cycle independent)

A

-work by cross-linking DNA strands + inhibiting proteins and DNA synthesis
–> can cause DNA mutations that lead to “secondary malignancies”
-cyclophosphamide + ifosfamide: produce a metabolite (acrolein) that concentrates in the bladder & can cause hemorrhagic cystitis
***must always dispense ifosfamide with mensa!

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59
Q

Alkylating Agents drugs

A

-cyclophosphamide –> SE: SAID
-ifosfamide (Ifex)
-Carmustine –> use non-PVC bag and tubing
-Busulfan –> SE= pulmonary toxicity
BBW: hemorrhagic cystitis

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60
Q

Platinum-based compounds facts

A

-cross-link DNA and interfere w/ DNA synthesis and cell replication
–> have toxicities similar to heavy metal poisoning = peripheral sensory neuropathy, ototoxicity & nephrotoxicity

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61
Q

Platinum-based compounds: Cisplatin

A

-nephrotoxicity, ototoxicity
*amifostine (Ethyol) is give to prevent nephrotoxicity
**HIGHLY emetogenic (give 3 N/V drugs)
**Limit dose to 100 mg/m2/cycle
SE: myelosuppression

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62
Q

Platinum-based compounds: Carboplatin

A

-myelosuppression is dose related
**dosed based on calvert formula: (Target AUC) (eGFR + 25)
AUC= 2-8, GFR capped at 125, may use crcl

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63
Q

Anthracycline Facts

A

-associated with cardiotoxicity (HR and cardiomyopathy)
-strong vesicants –> dexrazoxane is used as an antidote for accidental doxorubicin (Totect) extravasation
-protect from light during administration

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64
Q

How to reduce Doxorubicin Cardiotoxicity

A

-keep track of lifetime cumulative Doxorubicin dose = 450-550 mg/m2 [dose in mg/m2/cycle * total # of cycles]
-Dexrazoxane may be considered when the doxorubicin cum dose > 300 mg/m2

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65
Q

Anthracycline drugs: Doxorubicin (Adriamycin)

A

-potent vesicant
BBW: myocardial toxicity, vesicant, myelosuppression
–> color is RED (causes discoloration of urine, tears, sweat & saliva)
**do NOT exceed more than lifetime dose of 450-550 mg/m2
–> Dexrazoxane (Totect, Zinecard) for extravasation and cardioprotection)
SE: N/V

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66
Q

Anthracycline Drugs: Mitoxantrone

A

BBW: myocardial toxicity
–> drug is BLUE: causes blue urine, sclera and other body fluids

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67
Q

Vinca Alkaloids facts

A

-cause peripheral sensory and autonomic neuropathies (constipation)
*for IV use only, fatal if given by other routes (Vincristine –> also has CNS toxicity, CAPPED AT 2 MG/DOSE)
-vinblastine and vinorelbine associated with bone marrow suppression
-potent vesicants = antidote –> hyaluronidase and warm compress

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68
Q

Topoisomerase I inhibitor: Irinotecan (Camptosar)

A

-block th coiling and uncoiling of the double-stranded DNA helix during the S phase
“I ran to the can”–> acute anticholinergic symptoms (add atropine to the bag)
-delayed diarrhea (treat with loperamide)
BBW: myelosuppression, diarrhea

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69
Q

Topoisomerase II inhibitor: Bleomycin & Etoposide

A

-block the coiling and uncoiling of the double stranded DNA helic during the G2 phase
**max lifetime dose of 400 units d/t pulmonary toxicity risk & NOT mylosupressive :)
SE: hypersensitivity risk

-E capsules: need to be refrigerated
-infusion rate-relates hypotension: infuse for at least 30-60 mins

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70
Q

Taxanes drug facts

A

-inhibit the function of microtubules during the M phase
-peripheral sensory neuropathies + infusion-related hypersensitivity reactions & fatal anaphylaxis can occur w/ all (except abraxane- albumin bound)
SE: alopecia
**give taxanes before platinum-based compounds

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71
Q

Taxanes Drugs : PDC

A

-Paclitaxel: premedicate w/ diphenhydramine, steroids, H2RA
-Paclitaxel (albumin bound): no need to premedicate
-Docetaxel: premedicare with steroids for 3 days–> causes severe fluid retention
-Cabazitaxel: premed with diphenhydramine, steroid, H2RS (famatodine)

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72
Q

Pyrimidine Analog antimetabolites: Fluorouracil, 5-FU

A

-give w/ Leucovorin to inc efficacy (helps fu to bind more tightly to its target enzyme)
BBW: sin inc in INR
SE: hand-foot syndrome, diarrhea, muscositis
–> uridine triacetate (vistogard) can be given as antidote for overdose or toxicity due to DPD deficiency

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73
Q

Pyrimidine Analog antimetabolites: Capesitabine (Xeloda)

A

-oral prodrug of fluorouracil: 2 divided doses 12 hrs apart, given w/ water within 30 mins of a meal take for food
–> dihydropyrimidine dehydrogenase (DPD) deficiency inc risk of severe toxicity
SE: hand-foot syndrome, diarrhea, muscositis
–> uridine triacetate (vistogard) can be given as antidote for overdose or toxicity due to DPD deficiency

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74
Q

Folate antimetabolites facts

A

-block purine and pyrimidine biosynthesis during S phase
-folic acid +/- vitamin b12 may be required to reduce toxicity (myelosuppression, mucositis, diarrhea)
**w/ high doses of methotrexate –> give leucovorin/levoleucovorin “rescue” must be given

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75
Q

Folate antimetabolite: Methotrexate (Trexall)

A

-high dose (500 mg) requirs leucovorin
-hydration with IV sodium bicarb given to: alkalinize the urine & decrease nephrotoxicity
*Glucarpidase (voraxaze) given as antidote that rapidly lowers drug levels
DDI: NSAIDs, salicylates, PPIs
BBW: myelosuppression, renal damage, hepatotoxicity, tetratogencity
SE: nephrotoxicity, nausea, mucositis

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76
Q

Misc cancer drugs: Tretinoin

A

-do not use in pregnancy
-1st line for retonoic acid-acute promyelocytic leukemia syndrome

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77
Q

Misc cancer drugs: Arsenic trioxide

A

-worst/most QT prolonging drug

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78
Q

Misc cancer drug: Everolimus

A

-mTOR inhibitor: inhibits downstream regulation of vascular endotheilail growth factor (VEGF) reducing cell growth, metabolism, proliferation and angiogenesis
-SE: mouth ulcers, stomatitis, rash

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79
Q

Misc cancer drugs: Immunomodulators

A

-lenalidomide, pomalidomide, thalidomide
*cause the WORST birth defects = REMS drugs–> baby missing long bones in arms and legs

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80
Q

VEGF inhibitor: Bevacizumab (Avastin)

A

-impairs wound healing: do NOT administer for 28 days before or after surgery
BBW: severe/fatal bleeding , GI perforation

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81
Q

HER2 Inhibitors: Trastuzumab (Herceptin)

A

-only used for over expression of HER2 genes (HER2/NEU)
-cardiotoxicity

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82
Q

EGFR Inhibitor: Cetuximab (Erbitux)

A

-requires testing for KRAS wild type & EGFR + (used for NSCLC)
SE: acneiform rash (blisters and painful)–> indicates that a pt is expected to have a better outcome, treat with topical emollients (steroids, abx)

83
Q

Leukocyte cluster of differentiation CD antigens : Rituximab (Rituxan)

A

-premedicate with diphenhydramine, acetaminophen, steroids
-test for B-cell antigen CD20; must be CD20 positive to use
BBW: hep B reactivation, PML*, SJS/TEN

84
Q

Tyrosine Kinase Inhibitors: Imatinib (Gleevec)

A

must be philadelphia chromosome (BCR-ABL) positive to use
-oral drug
BBW: QT prolongation, vascular occlusions
SE: fluid retention, skin rash, diarrhea, hypothyroidism
-take with food

85
Q

DSM5 criteria for depression (M SIG E APS)

A

Mood*
Sleep
Interest/pleasure *
Guilt
Energy
Concentration
Appetite
Psychomotor agitation or retardation
Suicidal ideation
*must have symptoms 2 weeks and at least 5 symptoms, must have those 2

86
Q

Drugs that can cause or worsen depression

A

-ADHD meds: Atomoxetine (Strattera)
-Analgesics: Idomethacin
-Antiretrovirals (NNRTIs): Efavirenz, Rilpivirine
-Cardiovascular meds: BBs (propranolol)
-Hormones: BC, steroids
-Others: antidepressanrs, benzos, interferons, Varenicline, Ethanol

87
Q

What natural products are used for depression and what risks do they have?

A

-St. John’s wort: serotonin syndrome, CYP450 inducer (makes BC less effective), photosensitivity
-SAMe: serotonin syndrome, bleeding risk
-Valerian: sedations

88
Q

what are withdrawal symptoms of antidepressants?

A

BBW: suicidal thots and behaviors in peds and young adults
-anxiety, agitation, insomnia, dizziness, flu-like symptoms

89
Q

TCAs for depression SE/Safety/Monitoring

A

CI: do not use with MAOIs, linezolid, IV methylene blue
SE: QT prolongation, orthostasis, anticholinergic: dry mouth, blurred vision, urinary retention, constipation, weight gain, falls (BEERS LIST)

90
Q

TCA drug classes (2)

A

Tertiary amines: inc chilinergic effects, more effective
-Amitriptyline - give at QHS
-Doxepin- indicated for sleep as well
Seconday amines: more selective for NE, less SEs
-nortriptyline (pamelor)

91
Q

SSRI safety in pregnancy

A

-warning of persistent pulmonary HTN of the newborn
-NO paroxetine due to cardiac effects

92
Q

How to treat postpardum depression?

A

-breast feeding can help
-SSRI and TCAs are preferred (NO Dozepin)
-Brexanolone (C 4), has REMS, BBW for severe sedation

93
Q

SSRI & SNRI SE/Safety

A

CI: do not use with MAOI, Linex=zolid, Pimozide (used for turrets)
Warnings: QT prolongation (QT > 440, > 500 = TdP), liver disease, SIADH/hyponatremia, fall risk (BEERs), bleeding risk
SE: sexual dysfunction, CNS effects, dry mouth, nausea

94
Q

SSRI drugs (5)

A

Citalopram (Celexa): QT, MDD 40, elderly: 20mg
Escitalopram (Lexapro) QT, MDD 20, elderly 10 mg
Fluoxetine (Prozac): am dosing, long 1/2 life, no need to taper
Paroxetine (Paxil): sedation, take at pm [Brisdelle- usee for menopausal VS]
Sertraline (Zoloft) use in pts with cardiac risk

95
Q

SSRI combination drugs (2)

A

-Vilazodone (Vibryd)- SSRI + 5 HRIa partial agonist- take with food
-Voritioxetine (Trintellix)- SSRI + 5 HT3 anta + 5 H1A agonist –> less sexual side effects

96
Q

SNRIs (3)

A

-Venlafaxine (Effexor) : IR max dose = 375 mg, used for anxiety as well
-Duloxetine (Cymbalta): used for pain and anxiety
-Desvenlafaxine (Pristiq) only for depression
–> may increase BP, avoid in pts with uncontrolled BP

97
Q

DDIs with SSRI/SNRI

A

-serotonin syndrome or hypertensive crisis: use a 2 week washout from MAOi
-QT prolongation: noted with citalopram, escitalopram and venlafaxine
-Additive bleeding risk: anticoadulants, antiplatelets, fish oil, 5 gs (ginkgo, garlin, ginger, ginseng, glucosamine)
-CYP450 2D6 inhibitors: duloxetine, fluoxetine, paroxetine and tamoxifen

98
Q

Bupropion

A

-2nd line tx (use in pts who hd sexual SEs)
-dopamine and NE reuptake inhibitor
CI: seizure disorder (do not exceed 450 mf/day- risk inc with abrupt alcohol d/c), eating disorders (anorexia, bulimia), do not use w/ MAOi, IV methylblue or other forms of bupropion
Warnings: neuropsychiatric changes (mood, paranoia, aggression)
SE: dry mouth, insomnia, restlessness, weight loss (contrave)

99
Q

MAOi drugs (4)

A

3rd line- inhibit enzyme monoamine oxidase, hich breaks down 5-HT, NE, EPI and DA
Nonselective:
-Isocarboxazid (Marplan)
-Phenelzine (Nardil)
-Tranylcypromine (Parnate)
Selective:
-Selegiline (Emsam) - patch for depression and ODT version for parkinsons

100
Q

MAOi safety/SE

A

CI: DDIs, Drug-food interactions (tyramine rich = hypertensive crisis)
*use 2 week washout with: SSRI, SNRI, TCAs, bupropion
*use 5 week wash out with: fluoxetine

101
Q

Misc antidepressants (3)

A

-Mirtazapine (Remeraon): TCA, SE: increased appetite, weight gain, sedation, QT
-Trazadone: adminster QHS, sedation properties (BEERS), SE: priapism, QT
-Nefazodone: BBW- hepatotoxicity, (less sedating than trazadone)

102
Q

Selecting the best antidepressant: Cardiac/QT risk

A

**Sertraline preferred
-avoid high doses of citalopram and escitalopram
-watch for additive QT prolongation risk

103
Q

Selecting the Best Antidepressant: Smoking cessation

A

-Bupropion SR (indicated for both depression and smoking cessation)
-MDD: 300 mg/day

104
Q

Selecting the Best Antidepressant: Peripheral Neuropathy

A

Duloxetine

105
Q

Selecting the Best Antidepressant: Seizures

A

**avoid Bupropion in pts with seizures and eating disorder
-do not use in pts going through abrupt withdrawal = inc seizure risk

106
Q

Selecting the Best Antidepressant: Pregnancy

A

-psychotherapy for mild to moderate symptoms
-SSRI is preferred drug class (hypertension of newborn)
**DO NOT use paroxetine

107
Q

Selecting the Best Antidepressant: Sexual Dysfunction

A

-SSRI and SNRI have higher risk
-Bupropion and mirtazapine have lower risk

108
Q

treatment options for treatment resistant depression

A

-inc the dose of existing antidepressant
-change to a differnt antidepressant
-use a combo of antidepressants with diff mechanisms
–> augment with: Buspirone, atypical antipsychotic, lithium, esketamine and ECT

109
Q

Atypical antipsychotics used from tx resistant depression

A

–> depression that does not improve following 2 full tx trials ( 4-8 weeks at a therapeutic dose)
- Aripiprazole (abilify)
-Olanzapine/Fluoxetine (Symbyax)
-Quetiapine (seroquel)
-Brexpiprazole (Rexulti)
BBW: elderly individuals w/ dementia - related psychosis are at an inc risk of death

110
Q

Aripiprazole (abilify) SEs

A

anxiety, insomnia, akathesia (inability to stay still)

111
Q

Olanzapine/fluoxetine (Symbyax) SEs

A

CI: do not use with MAOi, linezolid, IV methylene blue
AE: sedation, weight gain, increased lipids, increased glucose

112
Q

Quetiapine (Seroquel AEs)

A

-sedation, orthostasis, weight gain, increased lipids, inceased glucose

113
Q

Brexpiprazole (Rexulti) AEs

A

weight gain, akathisia (agitation - dose dependent)

114
Q

Esketamine (Spravato)

A

*used for tx-resistant depression and depression with suicidality
BBW: sedation and dissociative or perceptual changes, potential for abuse and misuse
-REMS

115
Q

schizophrenia positive symptoms

A

-hallucinations
-delusions
-disorganized thinking and behavior

116
Q

schizophrenia negative symptoms

A

-flat affect
-poor hygiene
-lack of motivation (avolition)
-loss of speech (alogia)
-withdrawal

117
Q

Long acting injection antipsychotics (nonadherence)

A

-Haldol Decanoate (q 4 w)
-Risperdal Consta ( q 2 w)- risperadone
-Invega Sustenna (q 4 w), Invega Trinza (q 3 months) - paliparadone
-Abilify Maintena (q 4 w)- less metabolic issues, not as sedating

118
Q

Fast-acting Injection antipsychotics

A

–> used for acutely psychotic rn
-Haloperidol (shoot them up IM- Haldol + Ativan + benz or diphenhydramine)
-Fluphenazine
-Zyprexa
-Geodon
**do not use olanzepine and benzos together (orthostatsis)

119
Q

Orally Disintegrating Tablets (ODTs) (cheeking)

A

-Abilify Discmelt
-Clonzapine Fazaclo
-Risperdal M-Tab
-Zypreza Zydis
-Saphris (sublingual)

120
Q

*Meds/rec drugs that can cause psychotic symptoms

A

–> Anticholinergics ( high doses)
-dextromethorphan
-dopamine agonists
-Interferons
-Stimulants
-systemic steroids
–> Rec drugs
-bath salts
-cannabis
-cocaine
-LSD
-meth
-PCP

121
Q

BBW with antipsychotics

A

-increased risk of mortality in elderly pts w/ dementia related psychosis –> cardiovascular and infections
(mainly d/t the over use of risperadone)

122
Q

BBW for Clozapine

A

Must have failed 2 other APS or had bad AEs (TD)
-SEVERE Neutropenia (ANC > 1500 required to start, d/c if ANC < 1000)
–> must monitor q week x 6 months, q2 weeks x 6 months then q month for life
-seizures
-myocarditis and cardiomyopathy

123
Q

BBW: Thioridazine and Ziprasidone

A

*HIGHEST QT prolongation: (Thioridazine < Haloperidol < Ziprasidone)
–> higher risk TdP w/ low potassium, magnesium
–> D/C with QT > 500 msec
–> Dizziness, palpitations, syncope: cardiac evaluation

124
Q

1st gen APS (drugs and major SEs)

A

(L –> H Potency)
-Chlorpromazine
-Thioridazine
-Loxapine
-Perphenazine
-Haloperidol*
-Fluphenazine (comes in q 2 w IM)
-Thriothixene
-Trifluoperazine
AEs: Tardive Dyskinesia (elderly women at highest risk), dystonic reactions (young males at rik)

125
Q

*Important AEs of second generation APs

A

-Metabolic SEs (weight gain, inc cloes, glucose)
–>highest risk = clozapine, olanzapine, quitiapine
–>Mod risk: Risperidone, paliperidone
–>Low risk: Aripipazole, Ziprasidone, Lurasidone and asenpine
-EPS:
–>Low risk: quetiapine
-Hematological effects:
–> high risk: Ziprasidone
-Inc Prolactin:
–>High risk: Risperidone, paliperidone
-Seizure:
–> high risk: Clonazipine

126
Q

Antipsychotic drug interactions

A

-high levels of risperidone and paliperidone increase prolactin and cause EPS
-avoid drugs that lower seizure threshold w/ clozapine
-monitor for an increased risk of resp. depression and hypotension when adminstered with benzos ( DO NOT mix olanzapine with benzos)
-avoid other dopaime blocking agents such as metoclopramide ( do not want to use in the elderly- renal drug, 10 mg QID w/ meals E: 2.5- 5 mg): EPS and TD risk

127
Q

2nd gen antipsychotics

A

–> block dopamine and serotonin receptors
-Aripoprazole (abilify) - Maintena (q month), Astristrada (Q 4-8 w)
-Clonzapine (Clozaril) *must fail 2 other therapies first
-Lurasidone (latuda): sedating w/ at least 350 Kcal
-Olanzapine (Zyprexa) -Relprevv (2-4 w lasting inj) Q HS
-Paliperidone (Invega): - Sustenna (q month) Trinza (Q 3 mon) Hafyera (Q 6 mon) ghost tab in stool
-Quetoapine (Seroquel)
-Risperadone (Risperdol): Consta ( q 2 weeks)
-Ziprasidone (Geodon): Geodon- acute injection w/ food

128
Q

Neuroleptic Malignant Syndrome

A

**medical emergency! (rare but very dangerous- most common w/ FGAs and D2 blockers
-intense muscle contractions that can lead to acute renal injury (rabdo), suffocation and death
Signs: hyperthermia, muscle rigidity (* lead pipe rigidity), AMS, tachy, Labs: inc creatinine phosphokinase, & WBCs
TX: taper off antipsychotic quickly, use muscle relaxant (Dantrolene) –> use alt drugs like quetiapine or clozapine after)

129
Q

What is mania? (bipolar disorder)

A

Symptoms: inflated self-esteem, needs less sleep, more talkative than normal, jumping from topic to topic, easily distracted, increase in goal-directed activity, high risk, pleasurable activities
Definition: abnormally elevated or irritable mood for at least a week
Diagnosis: exhibits > 3 symptoms (if mood is only irritable, exhibits > 4 symptoms)

130
Q

Drug treatment for Bipolar Disorder

A

-Lithium and antieplileptic drugs (valproate, lamotrigine, carbamazepine) treat both mania and depression w/o inducing either state
*antidepressants can induce or exacerbate a manic episode when used as monotherapy, so they should only be used w/ a mood stabilizer

131
Q

acute treatment: manic episode

A

-1st line: antipsychotic (olanzapine, risperadone), lithium or valproate
–> combo of antipsychotic + lithium/valproate is preferred for severe episodes

132
Q

Acute treatment: depressive episode

A

1st line: antipsychotic (quetiapine, lurasidone), lithium, valproate or lamotrigine can be added or used as alternative

133
Q

second generation drugs used for Bipolar disorder

A

-aripiprazole (abilify, abilify mintena)
-olanzapine (zyprexa, Relprevv, Zydis)
-quetiapine (seroquel)
-risperidone (Risperdal)
-ziprasidone (Geodon)
-lurasidone (Latuda)
-olanzapine/fluoxetine (symbyax)

134
Q

Lithium

A

-influencing the reuptake of serotonin, NE or by modulating glutamate levels
–> dose: 300-900 mg/day (BID-TID)
-therapeutic range: 0.6-1.2 mEq/L (trough)
> 1.5 = ataxia, coarse hand tremor, vomiting
> 2.5 = CNS depression, arrhythmia, seizure

135
Q

Lithium SE/Safety

A

BBW: monitor serum levels for toxicity
Warnings: serotonin syndrome, renally cleared, avoid in pregos
SE: GI upset, cognitive effects, cogwheel rigidity, tremor, thirst, weight gain

136
Q

Lithium levels INCREASE with:

A
  • dec salt intake/sodium loss (with ACE/ARBs, thiazide diuretics)
  • NSAIDs: aspirin and sulindac are safer options
137
Q

Lithium levels DECREASE with:

A

-inc salt intake: caffeine and theophylline

138
Q

Increase risk of neurotoxicity when Lithium is taken with:

A

(ataxia, tremors, nausea)
-verapamil, diltiazem, phenytoin and carbamazepine

139
Q

*converting between lithium formulations

A
  • 5 mL lithium syrup = 8 mEq of lithium ion
    -8 mEq of lithium ion = 300 mg lithium carbonate tab/cap
140
Q

Drugs to use with pregnant bipolar disorder:

A

AVOID: valproate, carbamazepine, lithium
Safe: lamotrigine, lurasidone (bipolar depression)

141
Q

what conditions must be met for diagnosis of ADHD?

A

-several inattention or hyperactive-impulsive symptoms were present before the age of 12
-symptoms must have been present in 2 or more settings (home, school, work, w/ friends etc)
-symptoms interfere with functioning and are not caused by another disorder

142
Q

pt-friendly formulations for stimulants

A

-when putting capsule contents in food, use a small amount of food, eat the food right away; do not chew the beads
-capsule
-chewable tablet (Vyanse)
-orally-disintergrating tab
- patch (Daytrana)
- suspension

143
Q

Treatment of ADHD*

A

-stimulants are first line: (take in AM)
–> methylphenidate (concerta, Daytrana, Ritalin)
–> Lisdexamfetamine (Vyvanse)
–> Dexatroamphetamine/Amphetamine (Adderall)
-non-stimulants are second line: (take if risk of abuse)
–> Atomoxetine (Strattera)
-Add-on meds or can be used alone:
–> Guanfacine ER (Intuniv)
–> Clonidine ER (Kapvay)
-to help sleep at night:
–> Clonidine IR (Catapres)
–> Diphenhydramine
–> melatonin

144
Q

Stimulants BBW/CI/Warnings

A

BBW: high potential for abuse and dependence
CI: do not use within 14 days of MAOi (hypertensive crisis), HF, marked anxiety, tension, agitation, glaucoma
Warnings: inc HR and BP (cardio events), priapism, exacerbation of preexisting psychosis, inc risk of seizures, loss of appetite, serotonin syndrome

145
Q

Stimulants in ADHD: methylphenidates

A

-Ritalin (IR tab)
-Concerta (ER TAB): qam
-Ritalin LA (ER cap) Qam
-Daytrana (patch): apply 2 hrs before desired effect, remove after 9 hrs, alt. hips daily

146
Q

Stimulants in ADHD: Ampetamines

A

-Dextroamphetamine/Amphetamine (Adderall) –> misuse and sudden death
-Lisdexamfetamine (Vyvanse): capsule, chewable tab, low abuse potenial

147
Q

non-stimulant option for ADHD: selective norepinephrine reuptake inhibitor

A

Atomoxetine (Strattera) : BBW of suicidal ideation, no MAOi within 14 days, do not open capsule (ocular irritant)

148
Q

Non stimulat options for ADHD: Central Alpha-2A adrenergic receptor agonists

A

-Clonidine ER (Kapvay) qhs
-Clonidine IR (Catapres) for HTN
-Guafacine ER (Intuniv)
–> dose dependent cardio events, sedation and drowsiness
-do not d/c abruptly

149
Q

*drugs that cause anxiety

A

-albuterol (if used too frequently or incorrectly)
-Antipsychotics (apripiprazole, haloperidol)
-Bupropion
-Caffeine (in high doses)
-Decongestants (pseudoepherdrine)
-Illicit drugs (LSD, coke, meth)
-Levothyroxine
-Steroids
-Stimulants
-Theophylline

150
Q

Drug tx for anxiety: 1st line

A

-SSRI/SNRIs (slow titration, takes 4-6 weeks)
-Escitalopram (Lexapro)
-Fluoxetine (Prozac)
-Paroxetine (paxil)
-Sertraline (Zoloft)
-Duloxetine (Cymbalta)
-Venlafaxine (Effexor)

151
Q

2nd line tx for anxiety

A

-Buspirone (use in combo with antidepressant)
-TCA: Amitriptyline, Nortriptyline (Pamelor): not FDA approved
-Hydroxyzine (Vistaril): sedating, use for short term
-Pregalin (Lyrica) & Gabapentin (Neurontin): not FDA approved, can be used in pts with annxiety and neuropathic pain

152
Q

Special situations for anxiety tx

A

Propranolol (Inderal): not FDA-approved for anxiety but can reduce symptoms of stage fright or performance anxiety
-10-40 mg 1 hr prior to event

153
Q

Benzos better to use in elderly (LOT)

A

L: lorazepam (anxiety)
O: oxazepam (anxiety)
T: temazepam (insomnia)

154
Q

Benzos in anxiety

A

-Alprazolam (Xanax)
-Clonazepam (Klonopin)
-Diiazepam (Valium) : alcohol withdrawal
-Lorazepam (Ativan) : alcohol withdrawal
CI w/ opioids, severe liver disease, addictive

155
Q

*select drugs that can worsen insomnia

A

-alcohol
-antiretrovirals
-Apriprazole
-Atomoxetine
-Bupropion
-Caffeine
-Decongestants (pseudoephedrine)
-Diuretics (due to nocturia)
-Fluoxetine
-Steroids
-Stimulants
-Varenicline

156
Q

Need help falling asleep?

A

-Eszopiclone
-Ramelteon
-Zalplon
-Zolpidem

157
Q

Need help staying asleep?

A

-Doxepin
-Eszopiclone
-Survorexant
-Zolpidem

158
Q

Need help falling and staying asleep?

A

-Eszopiclone
-Zolpidem

159
Q

Hypnotics for sleep disorders

A

-C-IV! –> non benzos that increase GABA at the benzodiazepine receptors
-Zolpidem (Ambien)
-Zaleplon (Sonata)
-Eszopiclone (Lunesta)
AEs: CNS depression (next day impairement if < 7-8hrs of sleep), inc risk of resp depression, parasomnias (weird events while asleep)

160
Q

Orexin-receptor antagonist for sleep disorders

A

C-IV: blocks promotion of wakefullness
-Surovexant (Belsomra)
CI in narcolepsy
Warnings: sleep driving, abnormal thinking/behavior, sleep paralysis

161
Q

Melatonin Receptor Agonist for sleep disorders

A

-Ramelteon (Rozerem)
-Tasimelteon (Hetlioz) –> for non 24 hr sleep cycle ppl (like the blinds)

162
Q

Benzodiazepine use in insomnia

A

-C-IV, short term only!
-potentiate GABA
-Temazepam (Restoril)
Warnings & SE: drowsiness, ataxia, lightheadedness, anterograde amnesia,
-BEERS, but this one is on LOT = safer in olds

163
Q

Treatment for Restless Leg Syndrome

A

Dopamine agonists:
–> Pramipexole (Mirapex)
–> Ropinirole (Requip)
–> Rotigotine (Neupro) daily patch
AEs: orthostasis, somnolence
-Gabapentin encarbil (Horizant) –> approved fro RLS and postherpetic neuralgia (take with food)

164
Q

Drug tx for narcolepsy

A

Stimulants: C-IV
-Modafinil (Provigil)
-Armodafinil (Nuvigil)
–> Sodium oxybate (Xyrem) : C-III, REMs, “date rape drug” –> helps you sleep at night so you dont fall asleep during the day

165
Q

Dopamine blocking drugs that can worsen parkinsons disease *

A

-Prochloperozine and other phenothiozines (used for psychosis, nausea, agitation)
-Haloperidol or droperidol
-2nd gen Ags (risperidone and paliperidone)
-Metoclopramide (can accumulate in elderly)

166
Q

TRAP (motor) symptoms of Parkinsons Disease*

A

T: tremor when resting
R: rigidity in legs, arms, trunks and face (mask-like face)
A: akinesia/bradykinesia (lack of/slow start in movement
P: postural instability (inbalane/falls)

Others:shuffle walk, muffled speech, constipation, incontinence, frozen

167
Q

Parkinsons disease: tx for related psychiatric conditions

A

-Depression/Anxiety: SSRI/SNRI, TCA (desipramine, nortriptyline)
-Psychosis: quetiapine (AE: metabolic syndrome, orthostasis)

168
Q

PD tx: Carbidopa/Levodopa (Sinemet)

A

-this becomes dopamine
-separate from iron and protein rich food ( dec absorption)
SE: Nausea, dizziness, hallicunations, psychosis
DDI: phenothiazine, metoclopramide
–> use entacapone (Comtan) to make the drug last longer (200 mg with each dose of c/L)

169
Q

PD tx: Dopamine agonists

A

-Pramipexole (Mirapex) .125 mg TID
-Ropinirole (Requip) .25 mg TID
-Rotigotine (Neupro) patch- avoid in sulfite allergy, causes sweatyness
SE: somnolence, orthostasis, dyskinesia, dizziness, N/V

170
Q

PD tx: rescue therapy- Apomorphine (Apokyn)

A

-injection for those with severe diease (are frozen), lasts 45-90 mins
SE: SEVERE N/V, hypotension
-monitor supine and standing BP
-start antiemetic 3 days prior to dose: Trimetholbanzamide
**DO NOT USE ZOFRAN!

171
Q

what drug is best used for a younger pt with only parkinsons tremor?

A

-Benztropine (Cogentin) - has milder SEs
*do not use in the elderly

172
Q

Alzheimer’s disease symptoms *

A

-memory loss/getting lost
-difficulty communicating, repeating words and information
-difficulty with planning and organizing
-poor coordination and motor function
-personality changes
-inappropriate behavior
-paranoia, agitation, hallucinations

173
Q

Drugs that can worsen dementia *

A
  • antiemetics (promethazine)
    -antihistamines (diphenhydramine, dooxylamine)
    -antispychotics (chlopromazine, aripiprazole)
    -barbituates (phenobarbital, butalbital)
    -benzos (alprazolam, clonazepam)
    -central antichilonergics (benztropine)
    -skeletal muscle relaxants (baclofen)
    -CNS depressants: opioids
174
Q

what antipsychotic is FDA approved for agitation and psychosis in dementia?

A

Brexpiprazole (Rexulti)
–olanzapine is used off label as well
BBW: for increased mortalitiy and associated with increased rate of cog decline
–> LAST LINE in those with severe symptoms (lowest dose, shortest time)

175
Q

Acetylcholinesterase Inhibitors for Alzeimers disease

A

-can be used in ALL stages of disease, help to prevent ACH breakdown
-Donepezil (Aricept) : ODT, patch (7 days, fridge stored- back, butt or thigh), QTC*, use qhs
-Rivastigmine (Exelon): patch (daily, store at room temp- back, arm, or chest) , capsule
-Galantamine
Warnings: cardiac effects (bradycardia)
AEs: GI effects (titrate slowly- can go away after 3-4 weeks of use), insomnia
–> use w/ caution in pts < 55 kg

176
Q

NMDA Blockers for Alzheimers Disease TX

A

-moderate to severe disease (w/ ach inhibitor combo therapy)
-well tolerated
–> combo capsule: Namzaric (memantine + donepezil) - do not crush or chew, pt should already be stable on 10 mg donepezil before making this switch

177
Q

Drugs that can lower the seizure threshold*

A

-Analgesics: opioids (tramadol, meperidine)
-Anti-infectives: quinolones, carbapenems, cephalosporins, penicillins, lindane, mefloquine
-Psychiatric medicatoins: bupropion, clozapine (other antipsychotics), lithium, TCAs

178
Q

Siastat AcuDial Dispensing *

A

rectal gel for seizures- **Pharmacist must dial and lock correct prescribed dose
1- twist cap to adjust dose, confirm correct dose is visible in dosing window
2- lock dose by grasping locking ring at the bottom of syringe barrel and pushing it upward
3- green “READY” band is revealed

179
Q

acute seizure management

A

1- 0-5 mins: time the seizure, start ECG, )2 prn, BG, labs
2- 5-10 mins: give IV lorazepam, diazepam or IM midazolam (rectal diazempam, intranasal/buccal midazolam)
3- 20-40 mins: IV fosphenytoin, valproic acid, levetiracetam

180
Q

Antiepileptic drugs: Lamotrigine (Lamitacl)

A

-Na channel blocker
-start with 25mg daily dose for 2 weeks
BBW: SJS, toxic epidermal necrolysis –> inc risk w/ higher dose/escalation + valproate use
Warnings: asceptic meningitis, DRESS, cardiac rhythm abnormalities
SE: rash, alopecia, N/V, tremor, insomnia
**always use a starter kit (if missed for 6 days –> need to use this)

181
Q

Lamotrigine orange kit

A

“original”
-standard lamotrigine starter dose
–> use if not taking an interacting drug

182
Q

Lamotrigine Blue Kit

A

“below”
-lower lamotrigine starter dose
–> use if taking valproate (slows lam metabolism)

183
Q

Lamotrigine green kit

A

“grow”
-higher starter dose
–> use if taking enzyme inducer (leads to dec levels of lam)
-enzyme inducers = carbamazeoine, phenobarbital, phenytoin/fosphenytoin, primidone

184
Q

Antiepileptic drugs: Levetiracetam (Keppra)

A

-Ca chennel blocker, inc GABA)
Warnings: psychiatric reaction (psychosis symptoms, somolence, fatigue)
SE: behavior changes, dizziness, weakness
–> IV:PO ratio = 1:1
-no sig drug interactions
**preferred in: peds, pregnancy, when you have pts on multiple drugs (ex: BC)

185
Q

Antiepileptic drugs: Topiramate (Topamax)

A

-Na channel blocker (also used for migraine ppx)
Warnings: fetal harm, acid/base issues (hyperammonemia, esp when taken with valporate), oligonidrosis (reduced perspiration), angle closure glaucoma
SE: CNS depression, weight loss
–> can dec efficacy of BC

186
Q

Antiepileptic drugs: Valpoic acid, Divalproex (Depakote)

A

-inc GABA (used for bipolar + migraine ppx
BBW: hepatic failure, pancreatitis, fetal harm (neural tube defect)
Warnings: thrombocytopenia, hyperammonemia (tx with carnitine or lactulose)
SE: somnolence, tremor, weight gain, N/V, alopecia
***therapeutic range = 50-100 mcg/mL
–> can inc levels of: lamotrigine, phenobarbital, phenytoin, warfarin
–> drugs that dec VP levels: carbepenems, estrogen-containing contraceptives

187
Q

Antiepileptic drugs: Lacosamide (Vimpat)

A

*C-V
Warnings: cardiac effects (prolongs PR interval, inc risk of arrhythmias), dizziness, ataxia
SE: blurred vision, tremor, euphoria
–> IV:PO = 1:1
-use caution with drugs that affect PR interval (BB, CCB, digoxin)

188
Q

Antiepileptic drugs: Carbamazepine (Tegretol) and Oxcarbazepine (Trileptal)

A

both block NA channels, skin warnings, higher risk w/ HLA-B1502 allele (in Asians)
C:
-can be used in trigeminal neuralgia
BBW: serious skin warnings, aplastic anemia, agranulocytosis
CI: myelosuppression (dec blood cells)
Warnings: fetal harm, hyponatremia
–> therapeutic range: 4-12 mcg/mL
-autoinducer
O:
-not an auto inducer
-no aplastic anemia, agranulocytosis warnings

189
Q

Antiepileptic drugs: Phenytoin (Dilantin) & Fosphenytoin (Cerebyx)

A

–> IV:PO ration = 1:1 (1 mg = 1.5 mg fos)
BBW: hypotension, cardiac arrhythmias w/ rapid infusion
Warnings: extravasation = purple glove syndrome (edema/pain of skin), avoid use in HLB1502 + pts, fetal harm
SE:
–> acute: ataxia, diplopia, nystagmus (dose related)
–> Chronic: gingival hyperplasia, hair growth, herpatotoxicity

190
Q

IV Phenytoin*

A

-slow infusion (< 50 mg/min)
-monitor for BP, ECG, + resp
-dilute in NS, stable for 4 hours (DO NOT REFRIG)
-filter required

191
Q

IV Fosphenytoin*

A

-slow titration (< 150 mg/min)
-monitor for BP, ECG, resp
-lower risk of purple man syndrome

192
Q

NG tube phenytoin

A

-enteral feedings dec phenytoin absorption
-hold feedings 1-2 hour before and after admin

193
Q

Phenytoin correction*

A

(Total phenytoin measured) / (0.2 * albumin) + 0.1

–> only used for pts with albumin < 3.5 g/dL with crcl > 10 ml/min

194
Q

Antiepileptic drugs: Phenobarbital (Sezaby)

A

C-IV*
–> therapeutic range: 20-40 mcg/mL (adults)
Warnings: resp. depression, fetal harm, potenial for drug dependence
SE: residual sedation, dependence, tolerance
-primidone is a prodrug
-strong enzyme inducer
-can lower levels of hormonal BC

195
Q

Antiepileptic drugs: AE cousins: Carbamazepine, oxcarbazepine & eslicarbazepine *

A

-rash
-hyponatremia
-enzyme induction

196
Q

Antiepileptic drugs: AE cousins: phenobarbital & primidone

A

-sedation
-enzyme inducers
-overdose risk (dependence/tolerance)

197
Q

Antiepileptic drugs: AE cousins: Gabapentin & pregablin

A

-mild euphoria
-somnolence
-peripheral edema
-weight gain

198
Q

Antiepileptic drugs: AE cousins: Topiramate and zonisamide

A

-weight loss, metabolic acidosis
-nephrolithiasis
-oligohidrosis/hyperthemia

199
Q

Take you vitamins on AEDs*

A

All: calcium and vitamin D
Women of childbearing age: folate
Valproic acid: possibly carnitine
-lamotrigine and valproic acid: if alopecia occurs, sup with selenium and zinc

200
Q

AED: enzyme inducers

A

-carbamazepine
-oxacarbazepine
-phenytoin
-fosphenytoin
-phenobarbital
-primidone

201
Q

SED: enzyme inhibitor

A

-valporoic acid (inc lamotrigone)

202
Q

AEDS in pregnancy

A

-teratogenic risk: (neural tube defects)
highest = valproate
lowest = levetiracetam
–> give daily folate, calcium, and vit D supplementation
-dec oral contraceptive efficacy
-ASM monitoring (anti seizure meds decline during prego, need dose adjustments)

203
Q

AEDs in children

A

-CNS depressants (cog, difficulty, coordination issues)
-AEs:
–> topiramte and zonisamide: increase sweating = hyperthermia, dec sun exposure
-rash (lamotrigine)
-formulations= ODT, chewables or oral solutions

NAPLEX BABY (23 decks)

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