pharm Flashcards
1
Q
medications contributing to insomnia
A
Antidepressants
Stimulants
Antihypertensives
Sedatives
Decongestants and antihistamines Analgesics
Herbal supplements
Substances of abuse
2
Q
insomnia and comorbidity (i.e. GI, MSK, pscyh)
A
75%
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.
4
Q
benzidiapenes are what receptor agonist
A
GABA-A receptor agonist
5
Q
what do benzodiazepines allow for in GABA channel
A
Chloride ion move in and enhance GABA (inhibition)
6
Q
benzodiazepine effects
A
sedative and hypnotic
7
Q
use of benzodiazepines
A
short term or intermittent
only long term is severe or comorbid insomnia
8
Q
what not to combine benzodiapenes qith
A
other benzos
and alcohol or CNS depressants
9
Q
most addictive and quickest onset of action benzodiazepene
high risk of abuse, dependence and rebound insomnia
A
triazolam
10
Q
which benzodiazepen has a very long half life and should “never use”
A
flurazepam and nitrazepam
11
Q
best benzodiaepen for insomnia according to health canada
A
temezapam
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
13
Q
how long can u use benzos for
A
24 weeks
14
Q
when discontinue benzos what happens
A
rebound insomnia
gradual tapering helps
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
16
Q
Benzo receptor agonists (Z-DRUGS) vs benzodiapenzes
A
z drugs are allosteric modulator of GABA-A
benzos are GABA-A agonist
17
Q
preferred drugs for insomnia
A
z-drugs
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)
19
Q
z drug
A
zopiclone
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
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
22
Q
orexin function
A
orexin 1 and 2 promote arousal/wakefulness
23
Q
dual orexin antagonist example
A
lemborexant
24
Q
lemborexant/ dual orexin antagonist function
A
reduce wakefulness and unwanted transitions between wake and sleep
for: sleep onset and sleep maintenance isnomnia
25
lemborexant side benefits
no withdrawal or rebound insomnia
can use for 12 months
minimal next day impairment
minimal abuse potential
26
lemborexant adverse effects
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
27
contraindications for lemborexant
narcolepsy (bc possibly orexin dependent)
28
tricyclic antidepressant exmaple
doxepin
29
what receptor do TCAs work on
histamine H1 reeceptors
30
TCAs fro insomnia
use at low doses
high doses are for anxiety and depression
31
histamine receeptosr
agonist= wakeful
antagonist= sleep
32
health Canada indication for doxepin (TCA)
sleep-maintenance
33
how long can use doxepin fro
3 months
34
doxepin for what patient group with insomnia
elderly
bc no rebound insomnia, dependence or next day impairment
35
doxepin (TCA) adverse effects
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
36
off label agent for insomnis
sedation
- treat underlying comborditiy
centralized pain (fibromyalgia) --> anticonvulsants (i.e. gabapentin)
allergic conditions (ecemza, allergy) --> antihistamiens
mood disorders --> sedating antidepressants
37
insomnia in kids first line treatment
non-pharm
-
38
insomnia meds and kids
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
39
insomnia and eldery
*drug interactions
-want to limit sedation, cognitive impairment bc of falls
40
2 best sleep meds for insomnia in elderly
Low-dose doxepin for sleep-maintenance
Lemborexant has demonstrated a favourable safety and efficacy profile in the elderly up to 6 months of use
41
insomnia and pregnancy
sleep apnea and restless leg are bad
non-pharm 1st
42
best and worst sleep medications for pregnancy
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
43
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
D. zopiclone
44
acute treatment for headache
pain-free at 2 hours, headache relief at 2 hours, 24- hour sustained headache relief
45
3 most common headaches
tension-type headache, migraine, and medication-overuse headache
46
antiemetics examples and use
antinauseants (dimenhydrinate) and antiemetic (metocloramide)
help with N/V in headaches
47
best antiemetic for NV in headaches
metoclopramide
48
Analgesics for headahces use and examples
ASA and NSAIDs (naproxen and ibuprofen) bc more anti-inflammatory than acetaminophen
do not use opioid analgesics (withdrawal, medication induced headache)
49
adverse effects of analgesics
acetaminophen - hepatotexocity
NSAIDs- CVD risk, GI ulcers
use < 15 days/month to minimize development of medication overuse headache
50
ergot derivative example for headaches
dihydroergotamine mesylate
51
what does dihydroergotamine mesylate have affinity for in headahces
same as triptans but also dopamine and adrenergic receptors --> increase side effect potential
52
dihydroergotamine mesylate form
nasal spray or injectable
53
dihydroergotamine mesylate use
medication overuse headahces
(but can also cause MOH if use >10 days/month)
54
adverse effects of dihydroergotamine mesylate
chest pain, tingle, N/V, parenthesis, cramp, vasoconsrict, hypotesnion
55
contraindications of dihydroergotamine mesylate
Pregnancy
Cardiac disorders, hypertension, peripheral vascular disorders Sepsis
Liver disease
Peptic ulcer disease
Renal disease
56
triptans example
sumatriptan
57
when to take sumatriptan
early as possible in a migraine attack
58
sumatriptan form
inject, nasal spray, tablets, sub q injection (fast onset)
59
triptans use
rapid migraines with vomiting or present upon waking = sub q injection
N/V = nasal spray
exacerbated with water= orally disintegrating options
60
adverse effects of triptans
chest discomfort, fatigue, dizzy, parenthesis, drowsy, nausea, throat
use <10 days/month to avoid medication overuse headache s
61
contraindications for triptans
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
when not to use triptans
with ergotamines
within 24 hours of another triptan
with serotongeric meds
with MAOIs
63
CALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAGONISTS (CGRP-RA) example
ubrogepant
64
ubrogepant (CGRP-RA) use
for acute migraine when all other options failed
65
CGRP-RA function in headaches
CGRP is vasodilatory and pain transmission
*migriane related pain
66
ubrogepant (CGRP-RA) adverse effects
nausea, somnolence, dry mouth
increase CVD and cerebrovascular ischemic events
dont use with CYP3A4 inhibitors
67
medication overuse headache
taper off offending agents and start prophylactic therapy
68
prophylactic therapy for migraines
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
success in prophylactic therapy
>50% reduction in headache freqeuncey
if no benefit in2 months then change drugs
70
most evidence for beta blocker prophylactic headache drug
propanolol
also there's metoprolol and nadolol
71
adverse effects and contraindications of propanolol/ beta block in prophylactic headache treatment
fatigue, impotence, bradycardia and hypotension, GI symptoms, bronchospasm, heart failure, depression
Contraindicated in asthma, insulin dependent-diabetes, or heart block
72
TCA example for prophylactic headahce treatmetn
amitriptyline
73
when to use amitriptyline (TCA) prophylactic headaches
tension type headaches
74
CI for amitriptyline (TCA)
cardiac disease, glaucoma, prostate disease, or hypotension
75
example of angiotensin receptor blocker for prophylactic headaches
candesartan
76
how does candesartan (angiotensin receptor blocker) help with migraine prophylaxis
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
adverse effects from candesartan (angiotensin receptor blocker)
Lower risk of adverse effects, but can include hypotension, hyperkalemia, renal insufficiency, headache, dizziness
78
examples of antiepilectics for prophylactic headahce
valproic acid, divalproex sodium, topiramate, and
gabapentin
79
how do Valproic acid and divalproex sodium work on headaches
modulating GABA receptors in the trigeminovascular system and are effective in migraine prophylaxis
80
adverse effects of anti epileptics for prophylactic headache use
nausea, alopecia, tremor, weight gain, and increased hepatic enzymes
81
topiramate (antiepilepctic) adverse effects
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
gabapentin (anti epileptic) side effects in prophylactic headaches
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
example of CGRP monoclonal antibodies drug for prophylactic headaches
erenumab
84
erenumab for prophylactic headaches
subq injection
50% reduction in headaches
First-line preventative agents must have failed before qualifying for use
85
erenumab for prophylactic headaches side effects
njection site reactions, constipation, muscle spasms, pruritus, constipation, hypersensitivity reactions (may occur within minutes or more than 1 week after treatment), hypertension
86
headaches/migraines in pregnancy/breastfeedings
associated with a higher risk of maternal complications such as gestational hypertension, pre-eclampsia.
87
which medication for headaches/migraines in pregnancy/breastfeedings
acetaminophen
all others can be teratogenic
88
lactation effects on migraine
positive
89
medication for headaches/migraines in pregnancy/breastfeedings
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
headache in kids
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
which headache meds if breastfeeding
Propranolol does not appreciably pass into breast milk
Valproic acid, divalproex sodium, and topiramate are considered compatible
92
Which of the following medications can be used prophylactically to prevent migraine occurrence?
A. Sumatriptan
B. Dihydroergotamine
C. Gabapentin
D. Ibuprofen
C. Gabapentin
93
cognitive impairment from medications
anticholinergics
also: antidepressants, antiemetics, antihistamines, antimuscarinics, antipsychotics, hypnotics
94
cholinesterase inhibitors action
block metabolism of acetylcholine in synaptic cleft; increase acetylcholine and increase cholinergic transmission
95
main anti dementia mechication
donepezil (cholinesterase inhibitor)
for cognitive, function and behavioural symptoms
96
cholinesterase inhibitor example for dementia
donepezil
97
cholinesterase inhibitors effect on dementia
small effect; stabilization
98
for all severities of alzheimers and other neurological diseases of dementia
donepezil
99
adverse rxn of donepezil
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
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS example for dementia
memantine
101
NMDA receptor agonist function
block glutamate induced neuronal excitotoxiciity
102
memantine for what dementia
moderate to severe AD
not typically a monotherpay (use with donepezil)
103
adverse effects of mementine
dizziness (7%), headache (6%), confusion (6%), constipation (5%), nausea/vomiting (3%)
104
responsive behaviours in dementia
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
antidepressants for dementia
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
2 antipsychotics
risperidone and olanzapine
107
benzodiazepenes for dementia
sedate, falls, worsen cognition
but good for severe agitation
108
Which of the following adverse effects occurs most commonly with donepezil therapy?
A. Muscle cramps
B. Fatigue
C. Headache
D. Vomiting
C. Headache
along with nausea and diarrhea
