Parkinson's, Headache, Dementia Flashcards
1
Q
neuroanatomical and neurochemical processes leading to parkinsons
A
dopamine deficiency
loss of dopaminergic cells
formation of lewy bodies
2
Q
main symptoms of parkinsons
A
bradykinesia, rigidity, resting tremor, postural instability
3
Q
slowness and difficulty initiating voluntary movement
A
bradykinesia
4
Q
resistance to passive range of motion
A
rigidity
5
Q
occurs at rest abolished by movement but can progress to action
A
tremor
6
Q
motor symptoms of parkinsons
A
freezing, slow turning, decreased dexterity
7
Q
MOA of benztropine & trihexyphenidyl
A
anticholinergic- blocks acetylcholine at muscarinic receptors
8
Q
AEs of anticholinergics
A
possible link to cognitive impairment and decline***
mydriasis, dry mouth/skin, urinary retention, constipation, fever, mental change, flushed skin
9
Q
gold standard for parkinsons treatment that is a building block of dopamine
A
levodopa
10
Q
contraindications to l-dopa
A
breastfeeding, closed angle glaucoma, melanoma
11
Q
dopa-decarboxylase inhibitor that blocks peripheral l-dopa metabolism and is always given with l-dopa
A
carbidopa
12
Q
AEs of l-dopa
A
dopaminergic CNS/GI
dyskinesia, on-off, decreased effect w/ time, psych disturbances, vivid dreams, nausea, orthostatic hypotension, falls, urine/sweat/saliva discoloration, NMS w/ abrupt d/c (taper)
13
Q
DDIs of l-dopa
A
da antagonists, nonselective maois, high protein, iron salts, b6
14
Q
carbidopa dose needs to be maintained at what per day
A
at least 70-100 mg/day
15
Q
onset of effect with ER sinemet is
A
delayed
16
Q
intestinal gel form of l-dopa
A
duopa
17
Q
powder for inhalation form of l-dopa
A
Inbrija
18
Q
AEs of inbrija
A
blackens saliva and nasal secretions **
somnolence, hallucinations, dyskinesia, cough, URTI, nausea
19
Q
when is inbrija not recommended
A
asthma, COPD, other lung disease
20
Q
contraindications of inbrija
A
nonselective maoi within 2 weeks
21
Q
when is inbrija used
A
intermittent for off episodes, DOES NOT REPLACE PO
22
Q
reversible selective inhibitors of COMT that prevent breakdown of l-dopa and extend its effects
A
entacapone, tolcapone, opicapone
23
Q
are COMT inhibitors monotherapy or adjust
A
ADJUNCT ONLY- no effect in absence of L-dopa
24
Q
DDIs with COMT inhibitors
A
nonselective MAOIs*, drugs metabolized by COMT
25
when is entacapone administered
with each dose up carb/levo up to 8x a day
26
AE of entacapone
brown/orange urine
27
major AE/CI of tolcapone
risk for hepatocellular injury
CI with hepatic disease
28
opicapone dosing
once daily QHS
29
how is opicapone absorption affected by food
decreased absorption with high fat/calorie meals
30
noncompetitive, selective antagonists of MAO-B that decrease breakdown of DA and free radical production
selegiline
rasagiline
safinamide (xadago)
31
AEs of selegiline
insomnia, jitteriness*
HA, dopaminergic, HTN crisis, serotonin syndrome, etc.
32
caution with MAOI-B agents and foods containing
tyramine
33
is selegiline mono or adjunct
labeled adjunct, can be mono early
34
which MAO-B has 3 active amphetamine metabolites
selegiline
35
which MAO-B can be disease modifying
rasagiline
36
is rasagiline mono or adjunct
either
37
AEs of rasagiline
orthostasis, dopaminergic, HA, arthralgia, GI
38
most MAO-B agents have DDI with
nonspecific MAOIs, serotonergic drugs, sympathomimetics, tyramine foods
39
is safinamide (xadago) mono or adjunct
adjunct for wearing off
40
AEs of safinamide
dopaminergic, daytime somnolence, withdrawal NMS syndrome, retinal
41
CI to safinamide
child pugh C
42
agents that directly activate post synaptic DA receptors
pramiprexole
ropinrole
rotigotine
apomorphine
43
are DA agonists mono or adjunct
mono in healthy/young patients, or adjunct in case of deterioration in response to L-dopa
44
which type of AEs are more common with dopamine agonists? examples? in who?
nonmotor in older/frail
impulsive behaviors, psychosis, vivid dreams, daytime sedation
45
major DI of ropinrole with substrates of
CYP1A2
46
CI of ropinrole
abrupt d/c, hepatic disease
47
route of admin of rotigotine (neupro)
patch
48
rotigotine AEs
CNS, GI, peripheral edema, application site rxn*
49
caution with what when using rotigotine
heat & MRIs, allergy potential
50
when is apomorphine used
advanced PD PRN adjunctive treatment if unpredictable off or nonresponsive to other therapy
51
how is apomorphine initiated
test dose under supervision pretreated with an antiemetic
52
major DDI/CI of apomorphine
5HT3 antagonists increase hypotensive effects
53
AEs of apomorphine
dopaminergic, dizziness, falls, somnolence, chest pain
54
agent with poorly understood mechanism that increases endogenous DA
amantadine
55
effects of amantadine
decreases l-dopa induced dyskinesia*, and other parkinsons sx
56
ER amantadine (Gocovri) is only indicated for
l-dopa induced dyskinesia
57
amantadine needs dose adjustment for
renal impairment
58
AEs of amantadine
orthostatic hypotension, dizzy, falls, hallucinations, etc.
59
DIs of amantadine
LAIV, quinine/quinidine, HCTZ & triamterene
60
agent than blocks adenosine A2A receptor for parkinsons
istradefylline
61
is istradefylline used mono or adjunct
combo with carb/levo for patients with off episodes
62
when does istradefylline need dose adjustment
smokers
hepatic impairment
63
3 steps for management of PD psychosis
1. evaluate hypoxemia, infection, electrolyte disturbances
2. simplify drug regimen
3. add atypical antipsychotic
64
agents used for mild to mod migraine
NSAIDs, APAP, caffeine combos
65
agents used for mod to sev or refractory migraine
triptans, DHE, gepants, ditans
66
agents for refractory mod to sev migrain
triptan + NSAID, gepants, ditans, combo of analgesics with codeine or tramadol, opioids
67
2 oral solution NSAIDs for migraine TREATMENT
diclofenac potassium (Cambia)
celecoxib (elyxyb)
68
caffeine combo products with risk for dependence for migraine TREATMENT
butalbital/APAP/caffeine (Fioricet)
butalbital/ASA/caffeine (Fiorinal)
69
major AE of fioricet and fiorinal
risk for med overuse headache when taken >3 days/month
70
5HT1D AND 5HT1B selective agonists that cause vasoconstriction and reduce neurogenic inflammation.... for migraine TREATMENT
triptans
71
when & how are triptans best administered
early in course of attack, limit use to <10 days/month to prevent med overuse HA
72
AEs of triptans
flushing, chest pain, palpitations, dizziness, fatigue, xerostomia, serotonin syndrome
73
when are triptans avoided
CV or cerebrovascular conditions
74
which triptans have longest half lives
frovatriptan > naratriptan
75
which triptan has a lower AE incidence and is more tolerable
almotriptan
76
which triptan has the quickest onset of action
intranasal and SQ sumatriptan
77
which triptan has a higher AE incidence
sumatriptan
78
formulations of rizatriptan
PO, ODT, oral film
79
formulations of sumatriptan
PO, IN spray and powder, SQ
80
formulations of zolmitriptan
PO, ODT, IN
81
5HT1F agonist for migraine TREATMENT, CV
lasmiditan (reyvow)
82
administration key point for lasmiditan
must wait 8 hours between dosing and operating heavy machinery or driving
83
major AE of lasmiditan
CNS depression**
also serotonin syndrome, dec HR, inc BP, palpitations, etc.
84
small CGRP receptor antagonists for headache TREATMENT
gepants
rimegepant
ubrogepant
zavegepant
85
what is rimegepant (nurtec) indicated for
acute treatment and prophylaxis
86
nurtec dosing for prophylaxis
1 tab PO every other day
87
dosing of ubrogepant (ubrelvy)
1 tab once, can repeat after 2 hours
88
activate 5HT1D AND 5HT1B receptors on intracranial blood vessels and activates 5HT1D on sensory nerve endings for headache TREATMENT
ergots
ergotamine
dihydroergotamine
89
BBW for ergots
CI with potent 3A4 inhibitors (protease inhibitors, macrolides, -azoles).
90
major ergot AEs
cardiac valvular fibrosis, ergotism
91
when should ergots not be used
pregnant, breastfeeding, within 24 hours of triptans, other serotonin agonists, or ergotamine containing/ergot like agents
92
ergotamine AEs
NV (may worsen migraine associated NV), ECG changes, HTN, ischemia, etc.
93
additional CI for dihydroergotamine
ischemic heart disease, angina pectoris, MI hx, etc (other CV issues)
94
ergot other CI
pregnancy, PVD, CAD, hepatic/renal impairment, uncontrolled HTN, sepsis
95
options for migraine PROPHYLAXIS
nurtec
topiramate, valproic acid
beta blockers
TCAs, venlafaxine
qulipta (atogepant)
CGRP MAbs
nerve block
96
AEs of topiramate
cognitive dysfunction, CNS effect, nephrolithiasis, metabolic acidosis, angle closure glaucoma, oligoidrosis, hyperthermia, suicidal ideation, weight loss, paresthesia
97
counseling point for topiramate and when to avoid
important to stay hydrated
avoid in pregnancy
98
CI for valproic acid
prevention of migraine in pregnant women and women of childbearing potential who are not using effective contraception
99
dosing and AEs of TCAs for migraine prevention
lower doses than used for MDD
AE anticholinergic, cardiac conduction abnormalities
100
gepant used only for migraine prophylaxis taken once daily
atogepant (qulipta)
101
CGRP MAbs for migraine prevention
eptinezumab (vyepti)
erenumab (aimovig)
fremanezumab (ajovy)
galcanezumab (emgality)
102
which CGRPs bind the ligand? receptor?
ligand- vyepti, ajovy, emgality
receptor- aimovig
103
admin & AEs of vyepti
IV Q3M
infusion rxn, nasopharyngitis, nausea, inc. risk for Ab development
104
admin & AEs of aimovig
SQ QM
injection site rxn, constipation
105
amin & AE of ajovy
SQ QM or Q3M
injection site rxn
106
admin and AE of emgality
SQ QM
injection site rxn
107
alternative options for migraine prophylaxis
magnesium
B2
feverfew
butterbur
108
AEs of magnesium, how to manage
diarrhea, NV -- titrate dose
109
AE and when to avoid feverfew
GI AEs
avoid in pregnancy
110
AE and when to avoid butterbur
AE: GI, drowsy, fatigue, rash, hepatotoxicity
avoid products that aren't PA free
111
when is botox used
for chronic migraine
112
AE and BBW for botox
AE injection site pain, neck pain, myalgia, facial paresis
BBW spread of toxin effect
113
preferred agents for menstrual migraines
frovatriptan, naratriptan
114
when should estrogen containing CHCs be avoided
migraine with aura- stroke risk
115
first line for migraine in pregnant patients
APAP
116
major counseling point for tension HA
medication overuse HA
117
gold standard for prevention of cluster HA
verapamil
118
gold standard for hemicrania continua
indomethacin
119
2 types of thunderclap headaches that require immediate referral to the ED
reversible cerebral vasoconstriction syndrome
subarachnoid HA
120
max days/month for ergots, triptans, and opioids
<10
121
max days/month for non opioid analgesics
15 days
122
max days/month for butalbital
<4
123
which gene can increase risk for alzheimers
APOE4
124
what major neurotransmitter is decreased in alzheimers
acetylcholine
125
2 major things seen in the brain indicative of dementia
beta-amyloid plaques
neurofibrillary tangles
125
general pathophysiologic process of dementia
brain atrophy
ventricular enlargement
neuronal degeneration
low Ach
beta amyloid
tangles
126
what drugs could potentially increase dementia risk? examples?
cumulative anticholinergic use
antihistamines, TCAs, oxybutynin
127
drugs that block acetylcholinesterase therefore blocking metabolism of ACh
acetylcholinesterase inhibitors
donepezil
rivastigmine
galantamine
128
AEs of AChE inhibitors
sialorrhea, lacrimation, urination, defecation, GO, emesis (SLUDGE), bradycardia
129
major DDI/CI for AChEi drugs?
CI with baseline bradycardia or conduction system issues
DDI with drugs that induce bradycardia or alter AV node conduction
130
how to counsel if someone says their AChEi disrupts sleep? nausea?
sleep -- move dose to AM/earlier
nausea -- take with food or at bedtime
131
which AChEi have 2D6 and 3A4 metabolism
donepezil, galantamine
132
where can the rivastigmine patch be applied
back, chest, and arms only
poor absorption elsewhere
133
major AE of rivastigmine
GI disturbances
134
when should donepezil be taken (if tolerated)
bedtime
135
NMDA receptor antagonist
memantine
136
what is the combo pill with memantine ER?
+ donepezil
Namzaric
137
AEs of memantine
confusion (mild, transient), constipation, diarrhea
138
caution taking memantine if??
when does dose need adjusting??
caution if seizures or CV disease
lower dose if CrCl <30
139
anti-amyloid agents
lecanemab (Leqembi)
donanemab (Kisunla)
140
what is required to initiate an anti-amyloid
presence of amyloid beta pathology must be confirmed
141
major BBW for anti-amyloids
what increases risk
ARIA
increased risk with APoE4 carriers
142
lecanemab dosing
can it be d/c with improvement?
IV Q2W
no
143
donanemab dosing
can it be d/c with improvement?
IV Q4W
yes with threshold reduction of amyloid plaques
144
monitoring for anti-amyloid drugs
MRIs before and during treatment
145
antipsychotic indicated for agitation associated with dementia due to alzheimers
brexpiprazole (rexulti)
