Pharm (exam 1 material) Flashcards
1
Q
Duloxetine SE
A
Hepatotoxicity
2
Q
SSRI/SNRIs with highest risk of discontinuation syndrome
A
Paroxetine and venlafaxine
3
Q
Trazadone SE
A
Priapism, hypotension, sedation
4
Q
Mirtazapine SE
A
Weight gain
5
Q
Indication for amitriptyline (NOT MDD)
A
Migraine ppx
6
Q
S/sx of TCA overdose
A
Sinus tach ECG, seizures, sedation, anticholinergic effects
7
Q
TCA OD antidote
A
IV sodium bicarb
8
Q
Names of TCAs I can’t remember
A
Imipramine, clomipramine, doxepin
9
Q
Names of MOAIs I can’t remember
A
Isocarboxazid, tranylcypromine, phenelzine, selegiline
10
Q
MOAI interactions/CI
A
Uncontrolled HTN, CHF, pheo, high tyramine foods/ETOH (leads to HTN crisis, delirium)
11
Q
Earliest indicators of response to MDD tx:
A
Increased pleasure in activities
Improvements in psychomotor retardation
12
Q
Earliest indicators of response to MDD tx:
A
Increased pleasure in activities
Improvements in psychomotor retardation
13
Q
What do we screen for before starting an AD?
A
FH (1st deg) of bipolar disorder
AD monotherapy can precipitate mania
14
Q
When to start screening for depression and with what tool?
A
12yo w/ PHQ-2
15
Q
Childhood depression: start w/ ______ and add ______ if necessary
A
Psychotherapy, fluoxetine
16
Q
Switching from one class of ADs to another requires
A
Cross tapering (exception: SSRI to SNRI
17
Q
When to add an additional AD in a pt. already on one?
A
+ TLC and CBT first
18
Q
Buspirone indication
A
Augmentation (to AD and CBT) for anxiety
Safe in pregnancy!
19
Q
BZD antidote
A
Flumazenil
20
Q
BZD use…
- Short term bridging therapy for anxiety + panic attacks
- Status epilepticus
- Conscious sedation
A
- Alprazolam, lorazepam
- Lorazepam
- Diazepam, midazolam
21
Q
Withdrawal of what 3 drugs/substances can kill patients
A
BZDs , ETOH, barbituates
22
Q
BZD BBW
A
Concomitant use with opioids (resp. depression)
23
Q
BZDs w/ highest abuse potential
A
Alprazolam and diazepam
24
Q
AD used for OCD
A
Clomipramine (TCA) - cardiac eval first
25
Lithium MOA
Cation transport
| Influences reuptake of NE and 5HT
26
Lithium indications
Acute and maintenance of bipolar disorder
| *Most effective long-term therapy, decreases suicide risk AND short-term mortality*
27
Labs to check w/ lithium
Pregnancy test, CBC, BMP (hyponatremia, hypokalemia, hypercalcemia), renal fcn w/ BUN/CR and UA, TSH
28
What increases risk of lithium toxicity?
Renal dysfunction
29
Difference b/w 1st and 2nd gen APs
1st MORE dopamine, 2nd MORE serotonin
30
AP w/ the highest risk of EPS
Haloperidol
31
QT prolonging meds
AD, AP, antiemetics, antiarrhythmics, antimicrobials
32
Indication for chlorpromazine (1st gen AP)
Intractable hiccups
33
2nd gen APs that are good adjuncts for depression
Olanzapine, quetiapine, brex & aripiprazole
34
Tx for refractory schizoprenia
Clozapine
35
BBW for 2nd gen APs
Increased mortality in dementia-related psychosis
| Increased suicidality if depression
36
What must you do before rx an AP in a primary care setting?
Consult psych
37
AP ADRs:
1. Agranulocytosis
2. WORST DM and weight gain
3. Highest risk of QTc prolongation
4. Anaphylaxis/angioedema/type 1 HST rxn
5. Compulsive urges (eat, binge, shop, sex)
6. DRESS
1. Clozapine
2. Clozapine, olanzapine
3. Ilioperidone, ziprasidone
4. Asenapine
5. Aripirazole
6. Olanzapine, ziprasidone
38
Do positive or negative sx assoc. w/ schizophrenia respond better to AP?
Positive (e.g. hallucinations, delusions)
39
Extrapyramidal sx
```
Acute dystonia (1st few days) = torticollis
Pseudoparkinsonism (1st few weeks) = chorea, athetosis
Akathesia (1st few weeks) = creepy crawlies
Tardive dyskinesia = loss of muscle control affected face, arms, legs
```
40
Which EPS sx is irreversible?
Tardive dyskinesia
41
Tx of EPS
1. Reduce AP
2. If step 1 ineffective, switch AP
3. Benztropine (alternative: ER amantadine)
42
ACUTE phase bipolar tx:
1. Mania
2. Depression
1. AP, lithium, VPA
| 2. AP, lithium
43
MAINTENANCE phase:
1. Mania
2. Depression
3. Mixed
1. Lithium
2. Lamotrigine
3. Lithium +/- VPA, carbamazepine, lamotrigine
44
1st gen antihistamines
Diphenhydramine and doxylamine
45
Doxylamine indication
Nausea in pregnancy (1st line pharm agent, after lifestyle/dietary changes, vitamin B6)
46
Treatment of non-24hr sleep-wake disorder (blind pt.)
Tasimelteon
47
What type of stimulants are most commonly used for ADHD?
```
*Long-acting/ER*
Methylphenidate (Ritalin)
Dexmethylphenidate (Focalin)
Amphetamine/dextroamphetamine (Adderall)
Lisdexamphetamine (Vyvanse)
```
48
Stimulant MOA
Increase release of catcholamines from CNS synapses which leads to increased NE and DA in the brainstem (thought to increase attention span)
49
MOA of methylphenidate products
BLOCKS REUPTAKE of NE and DA
50
MOA of amphetamine products
PROMOTES RELEASE of NE and DA
51
Lisdexamphetamine is FDA approved for what non-ADHD condition
Binge-eating disorders
52
Interactions/ADRs of stimulants
- Diminish affect of anti-HTN drugs
- HTN crisis when used with MAOI and linezolid
- Increase HR and BP (caution w/ sympathomimetics/caffeine)
- Anxiety
- Appetite disturbance, wt. loss
- Sleep disturbance
- Sow growth rate in kids
- Precipitate tics in kids
- Lowers seizure threshold
53
What schedule drug are stimulants
II
54
T or F: ECG is indicated in all patients before initiating a stimulant?
False - healthy patients do not need one
55
CI to stimulants
- Underlying cardiac dz
- FH of tics, tourettes
- Marked anxiety
- Hyperthyroid
- Glaucoma
56
Atomoxetine MOA
SNRI-like (increases NE)
57
Atomoxetine BBW
SI
58
Role for atomoxetine in treating ADHD
Pt. intolerant of stimulant, h/o substance abuse, marked anxiety, anorexia
59
What medications are adjunctive to stimulants in treating ADHD?
Guanfacine (M/C) and clonidine
60
Fluoxetine and paroxetine inhibit what CYP enzyme
2D6 (think metoprolol)
61
Caution when adding SSRIs to other serotonergic drugs such as.....
Linezolid, St. John's wart, dextromethorphan
62
What SSRI poses the greatest risk of QT prolongation?
Citalopram
63
Serotonin syndrome vs. neuroleptic syndrome
```
SS:
- Onset w/in 12 hrs
- Hyperreflexia
- Increase muscle tone
- Dilated pupils
- Hyperactive bowel sounds
NMS:
- Onset w/in 1-3 days
- Hyporeflexia
- Lead-pipe rigidity
Both:
- Fever
- Hemodynamic instability (HTN, tachycardia)
- Hypersalivation, diaphoresis
```
64
Drugs that cause SS
Lithium, VPA, atypical APs, trazadone, buspirone, tramadol, benadryl, meperidine, linezolid, triptans, DM, methadone
65
Drugs that cause NMS
Compazine, phenergan, reglan, hydroxyzine OR withdrawal from dopamine agonist
66
Tx of SS and NMS
SS: Cyproheptadine (+/- NM blockade, intubation)
NMS: Bromocriptine or amantadine + dantrolene
Both: D/C offending agent, IVF, cooling blanket, lorazepam, +/- ECT
67
Max dose APAP for adults
4g/day
68
Antidote to APAP overdose
N-acetylcsteine
69
NSAIDs MOA
Reversibly inhibits COX 1 and/or COX2
70
NSAIDs should be used cautiously in pt. w/.....
- IBD
- HTN/HF, CAD, CVD, h/o TIA (avoid altogether in pt. w/ recent CABG)
- CKD (d/t prostaglandin inhibition -> dec renal BF and incr fluid retention)
- Asthma
- PUD
- Pregnancy
71
NSAID therapy....
1st line drugs:
2nd like drugs:
1st line drugs: Ibuprofen, naproxen
| 2nd like drugs: Meloxicam (safer for GI tract), piroxicam (safer for heart)
72
NSAIDs BBW
Increased CV risk
73
Why should we avoid diclofenac?
Prothrombotic + hepatotoxic
| *topical form better (OA, MSK injuries)
74
Which NSAIDs is most likely to cause nephortoxicity?
Ketorolac
75
NSAIDs interfere with the antiplatelet effect of what drug?
ASA - if have to be taken concomitantly, take ASA 1 hr before
76
What 3 drugs minimize GI side effects of NSAIDs?
Misoprostol
H2 blockers
PPI (preferred)
77
Celecoxib MOA
Selectively binds COX 2
78
What's unique about celecoxib?
Selective for COX 2, less GI toxicity, no antiplt effects
79
Indication for....
1. Cyclobenzaprine
2. Baclofen
3. Dantrolene
1. Short-term tx of MSK muscle spasms (acute, painful)
2. Neuromuscular conditions e.g. cerebral palsy
3. Malignant hyperthermia
80
Cyclobenzaprine SE
QTc prolongation
81
Dantrolene SE
Dose-dependent hepatotoxicity
82
Schedule II opioids
Codeine, hydrocodone, tapentadol
83
Which opioid should NEVER be used in children <18 or breastfeeding women?
Codeine
84
Codeine is a prodrug of what
Morphine
85
What CYP enzyme metabolizes codeine
2D6
86
What's the issue with CYP2D6?
10% of the population lacks the enzyme (cannot convert to active form)
1-30% are rapid metabolizers (toxicity)
87
Methadone MOA and indication
Mu agonist
| Pain and opioid rehab clinics
88
What opioid if combined with MAOI could lead to death?
Merperidine (serotonergic)
89
c/t other opioids, methadone has a higher risk of
Respiratory depression
90
Buprenorphine MOA and indication
Partial opioid agonist, opioid antagonist
| Pain and opioid rehab clinics (+ Naloxone = Suboxone)
91
Common opioid ADRs
- Euphoria
- Sedation
- Miosis
- Resp distress
- N/V
- Constipation
- Hyperalgesia
- Withdrawal
- Urinary retention
92
What medication can be used during opioid weaning for pt. c/o withdrawal sx?
Clonidine
93
Naloxone MOA
Competitive antagonist CNS opioid receptors
94
Naloxone pearls
- Reverses opioid w/in 1-3 minutes
- Short half life (60-90 minutes)
- Initial dose 0.4-2mg
- Available formulations: intranasal, SQ, IM, IV
95
Which opioid is category B in pregnancy?
Oxycodone
96
Triptans MOA
Selective agonist for serotonin receptors (causes vasoconstriction)
97
Avoid triptans in pt. w/
- Hemiplegic & basilar migraines
- Ischemic CVA/HD/vasospastic CAD/PAD, ischemic bowel, uncontrolled HTN, Raynaud's
- Severe hepatic impairment
- WPW
- Pregnancy
98
Factors that indicate need for migraine ppx
- Recurring migraines >4 per month
- Use of acute analgesics >2-3x/week
- CI to or failure or overuse or adverse effects of acute therapies
- Pt. preference
99
Migraine ppx options
- Propranolol
- AEDs: topiramate, VPA
- Amitriptyline
100
What 3 medications can prevent menstrual migraines?
Triptans, NSAIDs, OCPs
101
Dementia drugs
1. Sx treatment
2. Disease-modifying agent
1. Donepezil
| 2. Memantidine
102
Donepezil MOA
Cholinesterase inhibitor
103
Memantidine MOA
NMDA receptor agonist
104
Most effective symptomatic treatment for PD
Levodopa
105
Levodopa MOA
Naturally occurring amino acid, circulates in plasma to BB (dopamine cannot cross), decarboxylates to dopamine
106
Levodopa ADRs
- Motor fluctuations/on-off syndrome: >5 years
- Wearing off phenomenon: reemergence of PD sx <4 hrs following a dose
- N/V, anorexia
- CNS effects d/t chronic therapy, dose escalation (hallucination, sleep disturbance)
107
Carbidopa MOA
Blocks conversion of levodopa to dopamine systemically (inhibits peripheral decarboxylase)
+ minimizes side effects (N/V, orthostatic hypotension)
108
Drugs that should not be used concomitantly with PD meds
Anti-HTN, APs (1st gen >), nausea meds (promethazine, prochlorperazine, metochlopramide)
109
What drug is an alternative 1st line OR add-on therapy to levodopa/carbidopa? What about anther adjunct when levodopa efficacy is deteriorating?
Non-ergot derivatives (dopamine receptor agonists) e.g. ropinirole, pramipexole
Irreversible MOA-B inhibitors e.g. selegiline, rasagiline
110
Ropinirole indications (besides PD)
Restless leg syndrome
111
"Old" AEDs that require monitoring
Phenytoin
Carbamazapine
Valproate
112
Non-seizure indications for AEDs:
1. Gabapentin
2. Lamotrigine
3. Topiramate
4. CBZ
5. VPA
1. Neuropathy
2. Mood stabilizer
3. Migraine ppx, wt. loss
4. Trigeminal neuralgia, bipolar
5. Migraine ppx
113
Phenytoin is a CY.P.....
Inducer (speeds metabolism, reduces concxn of a drug)
114
Phenytoin ADRs
```
Gingival hypertrophy
Teratogenicity
Rash
Drug fever
Hepatotoxicity
*Nystagmus* = supratherapeutic dose
```
115
CBZ ADRs
```
BM suppression
Drug fever
SJS
Vitamin D deficiency
Teratogenicity (neural tube defects)
```
116
VPA ADRs
Teratogenicity (neural tube defects)
| Hepatotoxicity
117
Two opioids that are antidiarrheals
Diphenoxylate (+ atropine to dec addictive potential) and loperamide (dose not cross BBB -> no addictive potential)
