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NMt200 exam > pharm > Flashcards

pharm Flashcards

1
Q

medications contributing to insomnia

A

Antidepressants
Stimulants
Antihypertensives
Sedatives
Decongestants and antihistamines Analgesics
Herbal supplements
Substances of abuse

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2
Q

insomnia and comorbidity (i.e. GI, MSK, pscyh)

A

75%

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3
Q

sedative vs hypnotic

A

Sedative – A drug that reduces excitement and calms the patient. Also called anxiolytics. They do not induce sleep.

Hypnotic – A drug that results in drowsiness that promotes sleep.

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4
Q

benzidiapenes are what receptor agonist

A

GABA-A receptor agonist

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5
Q

what do benzodiazepines allow for in GABA channel

A

Chloride ion move in and enhance GABA (inhibition)

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6
Q

benzodiazepine effects

A

sedative and hypnotic

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7
Q

use of benzodiazepines

A

short term or intermittent

only long term is severe or comorbid insomnia

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8
Q

what not to combine benzodiapenes qith

A

other benzos

and alcohol or CNS depressants

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9
Q

most addictive and quickest onset of action benzodiazepene

high risk of abuse, dependence and rebound insomnia

A

triazolam

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10
Q

which benzodiazepen has a very long half life and should “never use”

A

flurazepam and nitrazepam

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11
Q

best benzodiaepen for insomnia according to health canada

A

temezapam

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12
Q

adverse effects of benzodiazepines

A

-ataxia, dizzy, withdraw, memory, abuse, next day impairment

-only use if 7-8 hours before awakening

-wait 12 hours before driving

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13
Q

how long can u use benzos for

A

24 weeks

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14
Q

when discontinue benzos what happens

A

rebound insomnia

gradual tapering helps

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15
Q

BENZODIAZEPINE RECEPTOR AGONISTS (Z-DRUGS) work on what

A

allosteric modulators of GABA-A receptors

presence of GABA does not facilitate action

enhances inhibition

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16
Q

Benzo receptor agonists (Z-DRUGS) vs benzodiapenzes

A

z drugs are allosteric modulator of GABA-A

benzos are GABA-A agonist

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17
Q

preferred drugs for insomnia

A

z-drugs

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18
Q

z-drugs vs benzo

A

similar effects on sleep

but z-drugs have: fewer adverse effects, less muscle relaxant affects, dont worsen sleep apnea and dont accumulate (less rebound on withdrawal)

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19
Q

z drug

A

zopiclone

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20
Q

adverse effects of z drugs

A

bitter/metalic taste, dry mouth, dizzy

sleep behaviours: night eating, somnambulism (sleepwalk)

impair next day activities

have is plan to sleep 7-8 hours and wait >12 hours to drive

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21
Q

what not to combine z drugs with

A

alcohol or CNS depressants

Increased risk of complex sleep behaviours in combination with other CNS-active drugs

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22
Q

orexin function

A

orexin 1 and 2 promote arousal/wakefulness

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23
Q

dual orexin antagonist example

A

lemborexant

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24
Q

lemborexant/ dual orexin antagonist function

A

reduce wakefulness and unwanted transitions between wake and sleep

for: sleep onset and sleep maintenance isnomnia

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25
Q

lemborexant side benefits

A

no withdrawal or rebound insomnia

can use for 12 months

minimal next day impairment

minimal abuse potential

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26
Q

lemborexant adverse effects

A

somnolence (drowsy), night eating, somnambulism (sleep walk)

less common: sleep paralysis, hallucinations, cataplexy

impair next day function, take if sleep fro 7-8 hours and not driving for 9 hours

cont combine with CNS depressant

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27
Q

contraindications for lemborexant

A

narcolepsy (bc possibly orexin dependent)

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28
Q

tricyclic antidepressant exmaple

A

doxepin

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29
Q

what receptor do TCAs work on

A

histamine H1 reeceptors

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30
Q

TCAs fro insomnia

A

use at low doses

high doses are for anxiety and depression

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31
Q

histamine receeptosr

A

agonist= wakeful
antagonist= sleep

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32
Q

health Canada indication for doxepin (TCA)

A

sleep-maintenance

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33
Q

how long can use doxepin fro

A

3 months

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34
Q

doxepin for what patient group with insomnia

A

elderly

bc no rebound insomnia, dependence or next day impairment

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35
Q

doxepin (TCA) adverse effects

A

since for insomnia is low dose usually no adverse

somnolence, sedation, nausea

dont combine w alcohol or CNS depressants

take within 3 hours of a meal to minimize drowsiness next day

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36
Q

off label agent for insomnis

A

sedation
- treat underlying comborditiy

centralized pain (fibromyalgia) –> anticonvulsants (i.e. gabapentin)

allergic conditions (ecemza, allergy) –> antihistamiens

mood disorders –> sedating antidepressants

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37
Q

insomnia in kids first line treatment

A

non-pharm

-

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38
Q

insomnia meds and kids

A

Although often used, over-the-counter antihistamine use is not recommended due to the risk of rapid tolerance, next-day sedation, cognitive impairment, and paradoxical reaction

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39
Q

insomnia and eldery

A

*drug interactions

-want to limit sedation, cognitive impairment bc of falls

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40
Q

2 best sleep meds for insomnia in elderly

A

Low-dose doxepin for sleep-maintenance

Lemborexant has demonstrated a favourable safety and efficacy profile in the elderly up to 6 months of use

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41
Q

insomnia and pregnancy

A

sleep apnea and restless leg are bad

non-pharm 1st

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42
Q

best and worst sleep medications for pregnancy

A

Zopiclone does not appear to be teratogenic and may be a reasonable choice if clinically justified

Benzodiazepines should be avoided, particularly in the first trimester, due to an increased risk of oral cleft; they may also cause neonatal withdrawal symptoms when used closer to term

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43
Q

A patient complains of a bitter taste in their mouth and dizziness following a recent prescription to help them sleep. Which of the following was most likely prescribed?
A. Doxepin
B. Lemborexant
C. Temazepam
D. Zopiclone

A

D. zopiclone

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44
Q

acute treatment for headache

A

pain-free at 2 hours, headache relief at 2 hours, 24- hour sustained headache relief

45
Q

3 most common headaches

A

tension-type headache, migraine, and medication-overuse headache

46
Q

antiemetics examples and use

A

antinauseants (dimenhydrinate) and antiemetic (metocloramide)

help with N/V in headaches

47
Q

best antiemetic for NV in headaches

A

metoclopramide

48
Q

Analgesics for headahces use and examples

A

ASA and NSAIDs (naproxen and ibuprofen) bc more anti-inflammatory than acetaminophen

do not use opioid analgesics (withdrawal, medication induced headache)

49
Q

adverse effects of analgesics

A

acetaminophen - hepatotexocity

NSAIDs- CVD risk, GI ulcers

use < 15 days/month to minimize development of medication overuse headache

50
Q

ergot derivative example for headaches

A

dihydroergotamine mesylate

51
Q

what does dihydroergotamine mesylate have affinity for in headahces

A

same as triptans but also dopamine and adrenergic receptors –> increase side effect potential

52
Q

dihydroergotamine mesylate form

A

nasal spray or injectable

53
Q

dihydroergotamine mesylate use

A

medication overuse headahces

(but can also cause MOH if use >10 days/month)

54
Q

adverse effects of dihydroergotamine mesylate

A

chest pain, tingle, N/V, parenthesis, cramp, vasoconsrict, hypotesnion

55
Q

contraindications of dihydroergotamine mesylate

A

Pregnancy
Cardiac disorders, hypertension, peripheral vascular disorders Sepsis
Liver disease
Peptic ulcer disease
Renal disease

56
Q

triptans example

A

sumatriptan

57
Q

when to take sumatriptan

A

early as possible in a migraine attack

58
Q

sumatriptan form

A

inject, nasal spray, tablets, sub q injection (fast onset)

59
Q

triptans use

A

rapid migraines with vomiting or present upon waking = sub q injection

N/V = nasal spray

exacerbated with water= orally disintegrating options

60
Q

adverse effects of triptans

A

chest discomfort, fatigue, dizzy, parenthesis, drowsy, nausea, throat

use <10 days/month to avoid medication overuse headache s

61
Q

contraindications for triptans

A

cardiac disorders, hypertension, basal and hemiplegic migraine

Basilar migraines originate in the brainstem and usually have an aura with dizziness, double vision, lack of coordination prior to the onset of pain

Hemiplegic migraines are rare and mimic strokes (one-sided weakness)

62
Q

when not to use triptans

A

with ergotamines

within 24 hours of another triptan

with serotongeric meds

with MAOIs

63
Q

CALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAGONISTS (CGRP-RA) example

A

ubrogepant

64
Q

ubrogepant (CGRP-RA) use

A

for acute migraine when all other options failed

65
Q

CGRP-RA function in headaches

A

CGRP is vasodilatory and pain transmission

*migriane related pain

66
Q

ubrogepant (CGRP-RA) adverse effects

A

nausea, somnolence, dry mouth

increase CVD and cerebrovascular ischemic events

dont use with CYP3A4 inhibitors

67
Q

medication overuse headache

A

taper off offending agents and start prophylactic therapy

68
Q

prophylactic therapy for migraines

A

Potentially useful when migraines have a significant impact on quality despite use of abortive therapy or if the frequency of attacks puts the patient at risk of medication overuse headache

69
Q

success in prophylactic therapy

A

> 50% reduction in headache freqeuncey

if no benefit in2 months then change drugs

70
Q

most evidence for beta blocker prophylactic headache drug

A

propanolol

also there’s metoprolol and nadolol

71
Q

adverse effects and contraindications of propanolol/ beta block in prophylactic headache treatment

A

fatigue, impotence, bradycardia and hypotension, GI symptoms, bronchospasm, heart failure, depression

Contraindicated in asthma, insulin dependent-diabetes, or heart block

72
Q

TCA example for prophylactic headahce treatmetn

A

amitriptyline

73
Q

when to use amitriptyline (TCA) prophylactic headaches

A

tension type headaches

74
Q

CI for amitriptyline (TCA)

A

cardiac disease, glaucoma, prostate disease, or hypotension

75
Q

example of angiotensin receptor blocker for prophylactic headaches

A

candesartan

76
Q

how does candesartan (angiotensin receptor blocker) help with migraine prophylaxis

A

Efficacy in migraine prophylaxis may be due to blocking the direct vasoconstriction, increased sympathetic discharge, and/or adrenal medullary catecholamine release mediated by angiotensin II

77
Q

adverse effects from candesartan (angiotensin receptor blocker)

A

Lower risk of adverse effects, but can include hypotension, hyperkalemia, renal insufficiency, headache, dizziness

78
Q

examples of antiepilectics for prophylactic headahce

A

valproic acid, divalproex sodium, topiramate, and
gabapentin

79
Q

how do Valproic acid and divalproex sodium work on headaches

A

modulating GABA receptors in the trigeminovascular system and are effective in migraine prophylaxis

80
Q

adverse effects of anti epileptics for prophylactic headache use

A

nausea, alopecia, tremor, weight gain, and increased hepatic enzymes

81
Q

topiramate (antiepilepctic) adverse effects

A

CNS effects (e.g., dizziness, ataxia, tremor, sedation, cognitive impairment), GI symptoms (e.g., nausea, dyspepsia, constipation), weight loss (can be beneficial in some patients)

May increase risk of nephrolithiasis

Cognitive side effects

82
Q

gabapentin (anti epileptic) side effects in prophylactic headaches

A

Generally well tolerated. Sedation is the most common adverse effect and it may be helpful for comorbid insomnia

Adverse effects include sedation, ataxia, tremor; less commonly, GI upset, peripheral edema, vision changes, weight gain, respiratory depression

83
Q

example of CGRP monoclonal antibodies drug for prophylactic headaches

A

erenumab

84
Q

erenumab for prophylactic headaches

A

subq injection

50% reduction in headaches

First-line preventative agents must have failed before qualifying for use

85
Q

erenumab for prophylactic headaches side effects

A

njection site reactions, constipation, muscle spasms, pruritus, constipation, hypersensitivity reactions (may occur within minutes or more than 1 week after treatment), hypertension

86
Q

headaches/migraines in pregnancy/breastfeedings

A

associated with a higher risk of maternal complications such as gestational hypertension, pre-eclampsia.

87
Q

which medication for headaches/migraines in pregnancy/breastfeedings

A

acetaminophen

all others can be teratogenic

88
Q

lactation effects on migraine

A

positive

89
Q

medication for headaches/migraines in pregnancy/breastfeedings

A

Acetaminophen the preferred agent for acute treatment

Ibuprofen is the NSAID of choice

Sumatriptan is considered compatible with breastfeeding

Metoclopramide is considered safe if needed adjunctively

90
Q

headache in kids

A

intermittent oral angalgesics:
ibuprofen > acetaminophen

avoid ASA if <15 yrs old bc Reye’s syndrome

N/V common
–> use metoclopramide

almotriptan if 12-18yrs old

Preventatively, only propranolol, topiramate, and amitriptyline

91
Q

which headache meds if breastfeeding

A

Propranolol does not appreciably pass into breast milk

Valproic acid, divalproex sodium, and topiramate are considered compatible

92
Q

Which of the following medications can be used prophylactically to prevent migraine occurrence?
A. Sumatriptan
B. Dihydroergotamine
C. Gabapentin
D. Ibuprofen

A

C. Gabapentin

93
Q

cognitive impairment from medications

A

anticholinergics

also: antidepressants, antiemetics, antihistamines, antimuscarinics, antipsychotics, hypnotics

94
Q

cholinesterase inhibitors action

A

block metabolism of acetylcholine in synaptic cleft; increase acetylcholine and increase cholinergic transmission

95
Q

main anti dementia mechication

A

donepezil (cholinesterase inhibitor)

for cognitive, function and behavioural symptoms

96
Q

cholinesterase inhibitor example for dementia

A

donepezil

97
Q

cholinesterase inhibitors effect on dementia

A

small effect; stabilization

98
Q

for all severities of alzheimers and other neurological diseases of dementia

A

donepezil

99
Q

adverse rxn of donepezil

A

diarrhea, nausea, vomiting, anorexia and/or weight loss, vivid dreams, tremor, vertigo, and other cholinergic effects (e.g., rhinorrhea, increased urinary frequency)

Headache, nausea, and diarrhea occur in more than 10%

100
Q

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS example for dementia

A

memantine

101
Q

NMDA receptor agonist function

A

block glutamate induced neuronal excitotoxiciity

102
Q

memantine for what dementia

A

moderate to severe AD

not typically a monotherpay (use with donepezil)

103
Q

adverse effects of mementine

A

dizziness (7%), headache (6%), confusion (6%), constipation (5%), nausea/vomiting (3%)

104
Q

responsive behaviours in dementia

A
  1. from underlying neurocongitve disorder (AD: depression and apathy –> psychosis and agitation)
  2. related to psychiatric (anxiety, depression)
  3. related to delirium (medical or environmental precipitant)
105
Q

antidepressants for dementia

A

dont use unless pre existing mental health problem

SSRIs less likely than TCAs to have anticholinergic side effects

(avoid TCAs)

–> mostly for anxiety: compulsive, agitation, sexually inappropriate behaviour

106
Q

2 antipsychotics

A

risperidone and olanzapine

107
Q

benzodiazepenes for dementia

A

sedate, falls, worsen cognition

but good for severe agitation

108
Q

Which of the following adverse effects occurs most commonly with donepezil therapy?
A. Muscle cramps
B. Fatigue
C. Headache
D. Vomiting

A

C. Headache

along with nausea and diarrhea

NMt200 exam (6 decks)

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