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Therapeutics > Parkinson's, Headache, Dementia > Flashcards

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

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2
Q

main symptoms of parkinsons

A

bradykinesia, rigidity, resting tremor, postural instability

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3
Q

slowness and difficulty initiating voluntary movement

A

bradykinesia

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4
Q

resistance to passive range of motion

A

rigidity

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5
Q

occurs at rest abolished by movement but can progress to action

A

tremor

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6
Q

motor symptoms of parkinsons

A

freezing, slow turning, decreased dexterity

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7
Q

MOA of benztropine & trihexyphenidyl

A

anticholinergic- blocks acetylcholine at muscarinic receptors

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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

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9
Q

gold standard for parkinsons treatment that is a building block of dopamine

A

levodopa

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10
Q

contraindications to l-dopa

A

breastfeeding, closed angle glaucoma, melanoma

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11
Q

dopa-decarboxylase inhibitor that blocks peripheral l-dopa metabolism and is always given with l-dopa

A

carbidopa

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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)

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13
Q

DDIs of l-dopa

A

da antagonists, nonselective maois, high protein, iron salts, b6

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14
Q

carbidopa dose needs to be maintained at what per day

A

at least 70-100 mg/day

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15
Q

onset of effect with ER sinemet is

A

delayed

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16
Q

intestinal gel form of l-dopa

A

duopa

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17
Q

powder for inhalation form of l-dopa

A

Inbrija

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18
Q

AEs of inbrija

A

blackens saliva and nasal secretions **
somnolence, hallucinations, dyskinesia, cough, URTI, nausea

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19
Q

when is inbrija not recommended

A

asthma, COPD, other lung disease

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20
Q

contraindications of inbrija

A

nonselective maoi within 2 weeks

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21
Q

when is inbrija used

A

intermittent for off episodes, DOES NOT REPLACE PO

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22
Q

reversible selective inhibitors of COMT that prevent breakdown of l-dopa and extend its effects

A

entacapone, tolcapone, opicapone

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23
Q

are COMT inhibitors monotherapy or adjust

A

ADJUNCT ONLY- no effect in absence of L-dopa

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24
Q

DDIs with COMT inhibitors

A

nonselective MAOIs*, drugs metabolized by COMT

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25
Q

when is entacapone administered

A

with each dose up carb/levo up to 8x a day

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26
Q

AE of entacapone

A

brown/orange urine

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27
Q

major AE/CI of tolcapone

A

risk for hepatocellular injury
CI with hepatic disease

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28
Q

opicapone dosing

A

once daily QHS

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29
Q

how is opicapone absorption affected by food

A

decreased absorption with high fat/calorie meals

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30
Q

noncompetitive, selective antagonists of MAO-B that decrease breakdown of DA and free radical production

A

selegiline
rasagiline
safinamide (xadago)

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31
Q

AEs of selegiline

A

insomnia, jitteriness*
HA, dopaminergic, HTN crisis, serotonin syndrome, etc.

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32
Q

caution with MAOI-B agents and foods containing

A

tyramine

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33
Q

is selegiline mono or adjunct

A

labeled adjunct, can be mono early

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34
Q

which MAO-B has 3 active amphetamine metabolites

A

selegiline

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35
Q

which MAO-B can be disease modifying

A

rasagiline

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36
Q

is rasagiline mono or adjunct

A

either

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37
Q

AEs of rasagiline

A

orthostasis, dopaminergic, HA, arthralgia, GI

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38
Q

most MAO-B agents have DDI with

A

nonspecific MAOIs, serotonergic drugs, sympathomimetics, tyramine foods

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39
Q

is safinamide (xadago) mono or adjunct

A

adjunct for wearing off

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40
Q

AEs of safinamide

A

dopaminergic, daytime somnolence, withdrawal NMS syndrome, retinal

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41
Q

CI to safinamide

A

child pugh C

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42
Q

agents that directly activate post synaptic DA receptors

A

pramiprexole
ropinrole
rotigotine
apomorphine

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43
Q

are DA agonists mono or adjunct

A

mono in healthy/young patients, or adjunct in case of deterioration in response to L-dopa

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44
Q

which type of AEs are more common with dopamine agonists? examples? in who?

A

nonmotor in older/frail
impulsive behaviors, psychosis, vivid dreams, daytime sedation

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45
Q

major DI of ropinrole with substrates of

A

CYP1A2

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46
Q

CI of ropinrole

A

abrupt d/c, hepatic disease

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47
Q

route of admin of rotigotine (neupro)

A

patch

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48
Q

rotigotine AEs

A

CNS, GI, peripheral edema, application site rxn*

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49
Q

caution with what when using rotigotine

A

heat & MRIs, allergy potential

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50
Q

when is apomorphine used

A

advanced PD PRN adjunctive treatment if unpredictable off or nonresponsive to other therapy

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51
Q

how is apomorphine initiated

A

test dose under supervision pretreated with an antiemetic

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52
Q

major DDI/CI of apomorphine

A

5HT3 antagonists increase hypotensive effects

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53
Q

AEs of apomorphine

A

dopaminergic, dizziness, falls, somnolence, chest pain

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54
Q

agent with poorly understood mechanism that increases endogenous DA

A

amantadine

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55
Q

effects of amantadine

A

decreases l-dopa induced dyskinesia*, and other parkinsons sx

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56
Q

ER amantadine (Gocovri) is only indicated for

A

l-dopa induced dyskinesia

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57
Q

amantadine needs dose adjustment for

A

renal impairment

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58
Q

AEs of amantadine

A

orthostatic hypotension, dizzy, falls, hallucinations, etc.

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59
Q

DIs of amantadine

A

LAIV, quinine/quinidine, HCTZ & triamterene

60
Q

agent than blocks adenosine A2A receptor for parkinsons

A

istradefylline

61
Q

is istradefylline used mono or adjunct

A

combo with carb/levo for patients with off episodes

62
Q

when does istradefylline need dose adjustment

A

smokers
hepatic impairment

63
Q

3 steps for management of PD psychosis

A
  1. evaluate hypoxemia, infection, electrolyte disturbances
  2. simplify drug regimen
  3. add atypical antipsychotic
64
Q

agents used for mild to mod migraine

A

NSAIDs, APAP, caffeine combos

65
Q

agents used for mod to sev or refractory migraine

A

triptans, DHE, gepants, ditans

66
Q

agents for refractory mod to sev migrain

A

triptan + NSAID, gepants, ditans, combo of analgesics with codeine or tramadol, opioids

67
Q

2 oral solution NSAIDs for migraine TREATMENT

A

diclofenac potassium (Cambia)
celecoxib (elyxyb)

68
Q

caffeine combo products with risk for dependence for migraine TREATMENT

A

butalbital/APAP/caffeine (Fioricet)
butalbital/ASA/caffeine (Fiorinal)

69
Q

major AE of fioricet and fiorinal

A

risk for med overuse headache when taken >3 days/month

70
Q

5HT1D AND 5HT1B selective agonists that cause vasoconstriction and reduce neurogenic inflammation…. for migraine TREATMENT

A

triptans

71
Q

when & how are triptans best administered

A

early in course of attack, limit use to <10 days/month to prevent med overuse HA

72
Q

AEs of triptans

A

flushing, chest pain, palpitations, dizziness, fatigue, xerostomia, serotonin syndrome

73
Q

when are triptans avoided

A

CV or cerebrovascular conditions

74
Q

which triptans have longest half lives

A

frovatriptan > naratriptan

75
Q

which triptan has a lower AE incidence and is more tolerable

A

almotriptan

76
Q

which triptan has the quickest onset of action

A

intranasal and SQ sumatriptan

77
Q

which triptan has a higher AE incidence

A

sumatriptan

78
Q

formulations of rizatriptan

A

PO, ODT, oral film

79
Q

formulations of sumatriptan

A

PO, IN spray and powder, SQ

80
Q

formulations of zolmitriptan

A

PO, ODT, IN

81
Q

5HT1F agonist for migraine TREATMENT, CV

A

lasmiditan (reyvow)

82
Q

administration key point for lasmiditan

A

must wait 8 hours between dosing and operating heavy machinery or driving

83
Q

major AE of lasmiditan

A

CNS depression**
also serotonin syndrome, dec HR, inc BP, palpitations, etc.

84
Q

small CGRP receptor antagonists for headache TREATMENT

A

gepants
rimegepant
ubrogepant
zavegepant

85
Q

what is rimegepant (nurtec) indicated for

A

acute treatment and prophylaxis

86
Q

nurtec dosing for prophylaxis

A

1 tab PO every other day

87
Q

dosing of ubrogepant (ubrelvy)

A

1 tab once, can repeat after 2 hours

88
Q

activate 5HT1D AND 5HT1B receptors on intracranial blood vessels and activates 5HT1D on sensory nerve endings for headache TREATMENT

A

ergots
ergotamine
dihydroergotamine

89
Q

BBW for ergots

A

CI with potent 3A4 inhibitors (protease inhibitors, macrolides, -azoles).

90
Q

major ergot AEs

A

cardiac valvular fibrosis, ergotism

91
Q

when should ergots not be used

A

pregnant, breastfeeding, within 24 hours of triptans, other serotonin agonists, or ergotamine containing/ergot like agents

92
Q

ergotamine AEs

A

NV (may worsen migraine associated NV), ECG changes, HTN, ischemia, etc.

93
Q

additional CI for dihydroergotamine

A

ischemic heart disease, angina pectoris, MI hx, etc (other CV issues)

94
Q

ergot other CI

A

pregnancy, PVD, CAD, hepatic/renal impairment, uncontrolled HTN, sepsis

95
Q

options for migraine PROPHYLAXIS

A

nurtec
topiramate, valproic acid
beta blockers
TCAs, venlafaxine
qulipta (atogepant)
CGRP MAbs
nerve block

96
Q

AEs of topiramate

A

cognitive dysfunction, CNS effect, nephrolithiasis, metabolic acidosis, angle closure glaucoma, oligoidrosis, hyperthermia, suicidal ideation, weight loss, paresthesia

97
Q

counseling point for topiramate and when to avoid

A

important to stay hydrated
avoid in pregnancy

98
Q

CI for valproic acid

A

prevention of migraine in pregnant women and women of childbearing potential who are not using effective contraception

99
Q

dosing and AEs of TCAs for migraine prevention

A

lower doses than used for MDD
AE anticholinergic, cardiac conduction abnormalities

100
Q

gepant used only for migraine prophylaxis taken once daily

A

atogepant (qulipta)

101
Q

CGRP MAbs for migraine prevention

A

eptinezumab (vyepti)
erenumab (aimovig)
fremanezumab (ajovy)
galcanezumab (emgality)

102
Q

which CGRPs bind the ligand? receptor?

A

ligand- vyepti, ajovy, emgality
receptor- aimovig

103
Q

admin & AEs of vyepti

A

IV Q3M
infusion rxn, nasopharyngitis, nausea, inc. risk for Ab development

104
Q

admin & AEs of aimovig

A

SQ QM
injection site rxn, constipation

105
Q

amin & AE of ajovy

A

SQ QM or Q3M
injection site rxn

106
Q

admin and AE of emgality

A

SQ QM
injection site rxn

107
Q

alternative options for migraine prophylaxis

A

magnesium
B2
feverfew
butterbur

108
Q

AEs of magnesium, how to manage

A

diarrhea, NV – titrate dose

109
Q

AE and when to avoid feverfew

A

GI AEs
avoid in pregnancy

110
Q

AE and when to avoid butterbur

A

AE: GI, drowsy, fatigue, rash, hepatotoxicity
avoid products that aren’t PA free

111
Q

when is botox used

A

for chronic migraine

112
Q

AE and BBW for botox

A

AE injection site pain, neck pain, myalgia, facial paresis
BBW spread of toxin effect

113
Q

preferred agents for menstrual migraines

A

frovatriptan, naratriptan

114
Q

when should estrogen containing CHCs be avoided

A

migraine with aura- stroke risk

115
Q

first line for migraine in pregnant patients

A

APAP

116
Q

major counseling point for tension HA

A

medication overuse HA

117
Q

gold standard for prevention of cluster HA

A

verapamil

118
Q

gold standard for hemicrania continua

A

indomethacin

119
Q

2 types of thunderclap headaches that require immediate referral to the ED

A

reversible cerebral vasoconstriction syndrome
subarachnoid HA

120
Q

max days/month for ergots, triptans, and opioids

A

<10

121
Q

max days/month for non opioid analgesics

A

15 days

122
Q

max days/month for butalbital

A

<4

123
Q

which gene can increase risk for alzheimers

A

APOE4

124
Q

what major neurotransmitter is decreased in alzheimers

A

acetylcholine

125
Q

2 major things seen in the brain indicative of dementia

A

beta-amyloid plaques
neurofibrillary tangles

125
Q

general pathophysiologic process of dementia

A

brain atrophy
ventricular enlargement
neuronal degeneration
low Ach
beta amyloid
tangles

126
Q

what drugs could potentially increase dementia risk? examples?

A

cumulative anticholinergic use

antihistamines, TCAs, oxybutynin

127
Q

drugs that block acetylcholinesterase therefore blocking metabolism of ACh

A

acetylcholinesterase inhibitors
donepezil
rivastigmine
galantamine

128
Q

AEs of AChE inhibitors

A

sialorrhea, lacrimation, urination, defecation, GO, emesis (SLUDGE), bradycardia

129
Q

major DDI/CI for AChEi drugs?

A

CI with baseline bradycardia or conduction system issues

DDI with drugs that induce bradycardia or alter AV node conduction

130
Q

how to counsel if someone says their AChEi disrupts sleep? nausea?

A

sleep – move dose to AM/earlier
nausea – take with food or at bedtime

131
Q

which AChEi have 2D6 and 3A4 metabolism

A

donepezil, galantamine

132
Q

where can the rivastigmine patch be applied

A

back, chest, and arms only

poor absorption elsewhere

133
Q

major AE of rivastigmine

A

GI disturbances

134
Q

when should donepezil be taken (if tolerated)

A

bedtime

135
Q

NMDA receptor antagonist

A

memantine

136
Q

what is the combo pill with memantine ER?

A

+ donepezil
Namzaric

137
Q

AEs of memantine

A

confusion (mild, transient), constipation, diarrhea

138
Q

caution taking memantine if??
when does dose need adjusting??

A

caution if seizures or CV disease
lower dose if CrCl <30

139
Q

anti-amyloid agents

A

lecanemab (Leqembi)
donanemab (Kisunla)

140
Q

what is required to initiate an anti-amyloid

A

presence of amyloid beta pathology must be confirmed

141
Q

major BBW for anti-amyloids
what increases risk

A

ARIA
increased risk with APoE4 carriers

142
Q

lecanemab dosing
can it be d/c with improvement?

A

IV Q2W
no

143
Q

donanemab dosing
can it be d/c with improvement?

A

IV Q4W
yes with threshold reduction of amyloid plaques

144
Q

monitoring for anti-amyloid drugs

A

MRIs before and during treatment

145
Q

antipsychotic indicated for agitation associated with dementia due to alzheimers

A

brexpiprazole (rexulti)

Therapeutics (29 decks)

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