Pharm: This Is the Last One Flashcards
1
Q
What are the criteria for a Major Depressive Episode?
Define Unipolar Depression?
Define Dysthymia
A
Lasting 2wks w/ five Sxs:
One must be: Depressed, Anhedonia
MDD
One major depressive episode w/ no hypo/mania
Persistent Depressive D/o
Depression lasting 2yrs w/ Sxs free periods lasting less than 2 consecutive months
2
Q
What are the facts about gender and suicide?
What are the 3 hypothesis behind depression?
A
Female: more likely to attempt, 2-4x higher during menopause
Male: more likely to complete
Biogenic Amine: dec levels of NT in brain
Dysregulation: failure of homeostasis
Neurochemical: 5HT/NE system must be functional for anti-depressant to work
3
Q
What are the 3 types of depression?
A
Reactive/Secondary- MC; response to grief, illness, drugs/ETOH
Unipolar: genetically determined and unable to experience pleasure/cope w/ life
Bi-Polar Affective: manic-depressive
4
Q
All medications classified as antidepressants increase concentrations of what 3 NTs?
What are the 3 ways to increase NT levels?
A
Dopamine NorEpi Serotonin
Inhibit reuptake
Block degredation
Inc NT release
5
Q
Continued use of TCAs/SSRIs/SNRIs cause what physiological changes of the receptors?
What structures project into limbic structures and release serotonin to be taken back up in ? neuron?
A
Down regulation of pre-synaptic autoreceptors, increases firing rate of raphae neurons
Raphe neurons
Presynaptic
6
Q
What are the Tertiary Amines?
What are the Secondary Amines
A
ADICT
Amitriptyline Doxepin Imipramine Clomipramine Trimipramine
DNP
Desipramine Nortriptyline Protriptyline
7
Q
Here do the issues of taking TCAs come in?
When are TCAs used in therapy?
A
Blockage of Histamine A-Adrenergic, and Muscarinic receptors AND NorEpi/Serotonin uptake
Seldom 1st line agents
Depression/Anxiety orders
Off label: pain syndrome, migraine prophylaxis
8
Q
What is the most common drug used in ODs?
What are some of the adverse reactions of using this drug class?
A
TCAs
Seizure Arrhythmias Coma Delerium
9
Q
What PTs should never receive TCAs?
Time frame of TCAs hence why such a gradual taper up is needed?
A
BPH CVDz Glaucoma SIs
2-4wks
10
Q
What are the adverse effects of taking TCAs?
What class of TCAs are “worse” w/ high sedation, anticholinergic and alpha blockage effects?
A
Anticholinergic
OHOTN
Drug interactions
Tertiary
11
Q
What TCAs cause weight gain?
What TCA is used for childhood enuresis and adult MDD?
A
Nortriptyline
Amitriptyline
Imipramine
12
Q
What TCA is used for depression and insomnia?
What TCA is used for OCD?
A
Doxepin
Clomipramine
13
Q
What drugs fall under SSRI group?
What are the two “other” SSRIs?
A
PFCS EF
Paroxetine Fluoxetine Citalopram Sertraline Escitalopram Fluvoxamine
Others: Villain Vortex
Vilazodone
Vortioxetine
14
Q
How long does it take for SSRIs to take effect?
SSRIs are first line choice for Tx of ?
A
3-8wks
PODS PPG Panic D/o OCD Depression Social Phobia PTSD Pre-menstrual dysmorphic d/o General anxiety d/o
15
Q
Which SSRI has the longest and shortest T1/2?
Only two SSRIs don’t interact w/ CYP450, which ones?
A
Long: Fluoxetine
Short: Fluvoxamine
Citalopram
Escitalopram
*most commonly prescribed, good for elderly PTs on multiple Rxs
16
Q
What SSRIs are the most and least CNS activating/sedating?
Which SSRI has the worse weight gain?
A
Most activate: Fluoxetine, Sertraline (avoid in insomnia, take in AM)
Most sedating: Paroxetine, Fluvoxamine (dose in PM)
Paroxetine
17
Q
What is a very common s/e of taking SSRIs?
What are three rare s/e?
A
Loss of labido (switch to Bupropion or add Silenafil)
Serotonin syndrome
SIADH
EPS s/e- akathisia, dystonia, parkinsonian Sxs (Paroxetine has the most)
18
Q
What is the triad of Serotonin Syndrome
How is it Tx?
A
Cognitive effects
Neuromuscular dysfunction
Autonomic dysfunction
Support: Benzos
Hyperthermia support
Cyproheptadine- 1st gen anti-histamine and 5HT antagonist
19
Q
Which SSRi can have abrupt discontinuation due to it’s long T1/2?
Which SSRI has FDA warning due to QTc prolongation and which one does NOT have this warning?
A
Fluoxetine
Citalopram above 40mg
Escitalopram
20
Q
SSRIs drug interactions include ?
What are the main SNRIs?
What are the others?
A
MAOIs ASA NSAIDs
Duloxetine
Venlafaxine
Desvenlafaxine
Levomilnacipram
Milnacipram
21
Q
What 3 SNRIs have been linked to increasing Diastolic BP?
What two drug classes should they not be used w/?
A
Venlafaxine
Desvenlafaxine
Duloxetine
MAOIs
Serotogenic agents
22
Q
Which SNRI has a dose-related effect on NorEpi?
What can Venlafaxine be used for?
A
Venlafaxine: <150mg/day is primarily a serotonin effect
Tx resistant depression
Gen Anxiety d/o
PTSD- 1st line w/ SSRI
23
Q
What are the benefits of using Venlafaxine?
What is the relation between Venlafaxine dosage and the NT blocked?
A
Safer than TCA for OD
Less activating as Fluoxetine
Unique MOA= use if SSRI have failed
SSRI effect at low dose
SNRI effect at high dose
24
Q
What are two adverse effects of using Venlafaxine?
Which SNRI is an active metabolite of another?
A
HTN
Serotonin syndrome if used w/ MAOI
Desvenlafaxine
25
What is Desvenlafaxine used for?
What is Duloxetine best used for?
2nd line for MDD
Diabetic neuropathy
Fibromyalgia
MSK pain
26
What PTs can't take Duloxetine?
Why would Levomilnacipram be used?
Liver/Renal dysfunction
As an isomer of Milnacipran, is a stronger NorEpi inhibitor for Depression
27
Milnacipran is only approved use is for ?
What are the s/e of using Levomilnacipram?
Fibromyalgia, not depression
HypoNa
Inc bleed risk
HTN/OHOTN
28
What is the site of action of the NDRIs?
What is the uses of Bupropion
Noradrenergic and dopamine releasing neuron
MDD
Smoking cessation
Off label for ADHD in kids/adolescents
29
What are the adverse effects of taking Bupropion?
What is a perk of using this drug over other anti-depressants?
Weight loss
Inc seizure risk
Less sex dysfunction
30
What drug interaction occurs w/ Bupropion?
What meds are fall under the classification of Serotonin Receptor Antagonist?
MAOIs, 14 day gap between use
MNT
Mirtazapine
Nefazodone
Trazodone
31
What are three common effects when taking SRAntagonists?
Antagonize serotonin, histamine and A1 receptors
32
MOA, Use, and Adverse effects of of SRA Trazadone
Inhibits serotonin uptake and antogonizes HT, A1 and H1 receptors but less than SSRIs
Sleep aid
Depression in combo w/ SS/NRI
Fewer s/e than TCAs
Drowsiness, OHOTN
33
MOA, Use, and Adverse of SRA Mirtazapine
Inhibits HT, H1, A1/A2 receptors but does NOT inhibit reuptake
MDD, better tolerated than TCAs
Used in combo w/ SSRI if PT has sleep d/o
Lower dose if CrCl <30mL/min
Low dose= sedative
High= insomnia
Constipation
34
MOA, Use and Adverse of SRA Nefazodone
Inhibits HT, A and reuptake of serotonin and NorEpi
Anxious depression
SSRIs causing sex dysfuntion
BBWarning: liver failure
35
MOA of the class of MAOIs
What are their adverse reactions?
Non-selective blocking of enzyme from breaking down NorEpi, Dopamine and Serotonin to inc concentration
```
Serotonin Syndrome
HTN Crisis
OHOTN
Weight gain
Sex dysfunction
```
36
What are MAOIs as a class used for?
What interactions do they have?
Atypical depression: Hypersomnia, Hyperphagia, Mood reactivity
PTs refractory to other anti-depressant agents
Increases tyramine, increases release of Epi /NorEpi causing HTN crisis
37
What MAOI are considered last line?
What interactions do they have?
Antidepressant med can be considered a Tx failure if no improvement is seen in what time frame?
Tranylcypromine
Decongestants, Cheese plates/drinks
Lack of reduction of Sxs by more than 50% within 8-12wks
38
How long do PTs need to wait after d/c antidepressant and starting an MAOI?
Facts about Selegiline
2 wks
Except Fluoxetine- wait 6wks
Transdermal patch w/ fewer s/e like weight gain, sex dysfunction due to MAO-B inhibition
39
What medications can cause major and minor sexual dysfunction?
What two antidepressants are less likely to cause weight gain?
Buproprion- more rare Sxs
Mirtazapine- lower than S/NRI
S/NRI- reduce libido, prevent ED/orgasms
Buproprion, Fluoxetine
40
What antidepressants cause somnolence?
Which ones can increase energy?
Paroxetine Mirtazapine TCAs
Trazadone
Burproprion, SNRI
Fluoxetine, Sertraline more activating than other SSRIs
41
What drug can increase anxiety and what medications are recommended to use?
Which medications can reduce pain?
Buproprion can cause, S/NRI if PT experiences anxiety
Duloxetine, Venlafaxine (fibromyalgia + depression)
Amitriptyline and Imipramine- diabetic neuropathy
42
Which medications are indicated for use in diabetic neuropathy?
Which antidepressant specifically has shown to cause heart defects in fetuses?
Amitriptyline, Imipramine
Paroxetine
43
# Define Mania
Define Hypomania
Define Cyclothymic d/o
1wk of abnormal and persistently elevated mood
Four days or more without impairing social/occupation and not psychosis
Several hypomania periods, mild depression
44
# Define BP1
Define BP2
Recurrent manic/mixed manic more frequent/severe than depression
One or more depressive epidosdes w/ one hypomaniac episode w/ no mania
45
What is the criteria for rapid cycling for Bipolar D/o
What needs to be assessed in these PTs?
What are thought to be the culprit of causing manic episodes?
Four or more episodes of mania, hypomania, mixed or depression withing one year
Thyroid
Over production of NorEpi and Serotonin
46
What are the 5 classes of drugs used for the management of Bipolar D/o?
Lithium
Anticonvulsant (Val-TLC))
Antipsychotics (all atypicals except Clozapine, Iloperiodone)
Benzos (Lorazepam, Diazepam)
Antidepressants (not as monotherapy and not during manic episodes)
47
MOA and Use of Lithium
Neuroprotective, inhibits transduction
Mood stabilizer during mania
Not for rapid cycles
Used in conjunction w/ Anti-psych or Benzo, d/c anti-psych after manic episode stops
48
What monitoring needs to be done on PTs taking Lithium
What type of conditions can raise Lithium levels in a PT to toxic levels?
PET CURE
Pregnancy E+ Thyroid CBC UA Renal function ECG
```
ACEIs/ARBs
NSAIDs- inhibits prostaglandins
Diuretics
Dehydration/Fever/Vomit
Crash/Na restricted diets
```
49
What are the adverse effects of taking Lithium
What is done for PTs taking Lithium that have tremors, hypothyroid, polyuria/dyspia?
Sedation
Edema/weight gain
Nephrogenic DI
Dec thyroid funtion
BB
Levothyroxine
Lowest dose possible
50
How are PTs w/ Lithium toxicity Tx?
When are anticonvulsants preferred for Bipolar PTs?
Hydrated
Gastric lavage
>3mEq- dialysis
Rapid cycles
Substance abuse
2* bipolar/mixed mania
51
What is the DOC for Bipolar PTs that are manic or have >4 manic episodes/year?
What are the adverse effects of taking these medications?
Valproic acid
Divalproex sodium
Neurotoxicity
Hair loss
Teratogenic- Cat D, causes Spina Bifida
52
When is Carbamazepine used for Bipolar?
Prior to Rx this, PTs need to be screened for ?
Mania and maintenance when improvement isn't reached w/ only Lithium
HLA B 1502 enzyme- mutation increases risk of Steven Johnson Syndrome
53
What are the adverse effect of Carbamzepine
What Bipolar drug is only used for maintenance/depression phase?
SIADH HypoNa SJS
Lamotrigine
54
How does Lamotrigine interact w/ other Bipolar drugs?
When/why are Benzos added to Bipolar medication regimes?
Valproic acid- dec metabolism
Carbamazepine- inc metabolism
Agitation, Insomnia, Hyperactivity
55
Which benzos are used in the acute setting of Bipolar?
Which one is briefly used for behavior Sxs?
Lorazepam
Diazepam
Clonazepam
56
What are the Anti-Pyschs/Neuroleptics used for Bipolar?
Haloperidol/Olanzapine- control agitation/psychosis
Aripiprazole/Olanzapine- mono therapy for maintenance
Quetiapine- FDA approval for depression and maintenance
57
What is the pathyphysiology of Parkinson's?
Unbalanced dopamine/ACh neurons
Dopamine inhibits GABA, ACh excites GABA
Parkinson's= loss of dopamine neurons, inc of ACh unopposed
58
Since dopamine can't cross BBB, what drug is given to Parkinson's PTs that can cross?
What drugs can cause Parkinsonian like s/e?
What type of infection can cause these S/Sxs?
L-Dopa
Anti-psychotics (PCTT-zine, Haldol)
Antiemetic
Metoclopramide
Viral encephalitis
59
What class of meds are used for Parkinson's motor disability improvement?
Which ones are used for motor complications?
Levodopa
Dopamine agonsits
60
How is Parkinson's managed in a young, fit PT w/ no comorbidities and mild Sxs?
```
MAOI (Rasa/Selegiline)
Dopamine agonist (non-ergot)
```
```
L-Dopa (Carel/Beneldopa)
COMT inhibitor (Enta/Tolcapone)
```
61
How is Parkinson's managed in frail PT w/ comorbidities and cognitive impairment?
What is done for PTs w/ dyskinesia, severe motor fluctuations or resistant tremors?
L-Dopa (Carel/Beneldopa)
MAOI (Rasa/Selegiline)
COMT (Enta/Tolcapone)
D: reduce L-Dopa, add Amantadine
S: SQ Apomorphine or Duodopa
R: Deep brain stimulation
62
What drug class is the first line for Parkinson's w/ Sxs?
This drug has the greatest effect on ? but not on ? Sxs
Dopamine agonists
Best: Bradykinesia, Rigidity (Levodopa)
Low: Tremor, Posture instability
63
What 3 circumstances is Levodopa the initial therapy for Parkinson's?
What drug class is most useful in Parkinson's PTs w/ tremors?
>70y/o
Dementia
Cognitive impairment
Anticholinergic
64
When/why would a NMDA receptor inhibitor be given to a Parkinson's PT?
Dec dyskinesia from Levodopa/Dopamine agonist
65
What are the Dopamine Agonists?
What are the Dopamine Analogs?
RAP Bro
Ropinirole Apomorphine Pramipexole Bromocriptine
Levodopa/Carbidopa
66
What are the Muscarinic Antagonists/Anticholinergics used in Parkinson's?
What is the NMDA receptor inhibitor med used?
Benztropine, Trihexyphenidyl
Amantadine
67
What two classes of drugs are used to decrease catabolism in Parkinson's PTs?
What are the two types of Dopamine agonists?
COMT Inhibs: Tol/Enta/capone, Carbi/Levodopa
MAOIs: Sele/Rasagline
Ergot vs Nonergot
68
What is the first line monotherapy for Parkinson Sxs and why is this important?
Use caution when giving this to ? PT populations
Dopamine agonists- delay need for Levodopa (short efficacy) in younger PTs for years.
Less dyskinesia/fluctuations
Psychosis, Dementia
69
Which two dopamine agonists are non-selective?
What are adverse reactions that can occur w/ use?
Bromocriptine- rarely used, semi synthetic ergot derivative
Rotigotine- non-ergot, transdermal
Cardiac/pulmonary fibrosis
OHTON
Hallucinations
70
Which dopamine agonists are selective?
Both of these Non-Ergots have FDA approval for ?
What are the a/e and c/i?
Pramipexole
Ropoinirole
RLS
Adverse: OHOTN, hallucination
C/i: psychotic illness, recent MI, active peptic ulcer
71
Pramipexole usages
Possible beneficial effect
Monotherapy for mild Parkinson's
PTs w/ advanced Dz
Neuro-protective- scavenges hydrogen peroxide= enhanced neurotrophic activity
72
Ropinirole usage
What is a benefit of adding this med?
Monotherapy w/ mild Parkinson's
Reduces dosage need of Levodopa needed
73
What is Apomorphine used for?
What needs to be monitored on these PTs?
What happens if the PT misses a week worth of doses?
Tx of 'off' episodes of Parkinson's
BP
Restart Tx program w/ BP monitoring
74
What is the most common s/e of taking Apomorphine?
How can this reaction be avoided?
N/V
Pre-treat w/ Trimethobenzmide 3 days prior
75
What meds are c/i when using Apomorphine?
What type of PT allergy needs to be pre-screened?
5HT3 antagonists- severe HOTN or LoC
Sulfite sensitivity
76
What's the difference between Carbidopa and Levodopa?
What is the MOA of Carbidopa?
Carb- no BB crossing
Levo- crosses BBB, converted to dopamine in periphery
Prevent AAD from reducing L-Dopa into Dopamine in the peripheral tissue where dopamine is not needed
77
How is excess dopamine induced dyskinesia managed?
How is the "wearing-off" effect of Parkinson Tx managed?
Dec Levodopa
Add anticholinergic
Add Amantadine
Add MAO-B
Add COMT inhibitor or,
Shorten L-dopa dosing interval
78
How is the "on-off" phenomenon of Parkinson's Tx?
What caution needs to be taken when giving L-dopa?
Add dopamine agonist
Add MAO-B
Add COMT inhib
Inc dietary protein
Levodopa- skin CA precursor, may activate cancer
79
PTs on MAO-B inhibitors need to avoid ? meds
MOA of Selegiline
Any that increase risk of Serotonin Syndrome
Irreversibly inhibits dopamine metabolism w/out inhibiting MAO-A= lower HTN crisis risk
Last dose taken in early afternoon (drug is metabolized into amphetamine)
80
When would MAO-B Selegiline be used as monotherapy?
Benefits of Rasagiline use
Mild Parkinson's Dz to delay need fo LDopa
Sx relief and neuroprotection
5x more potent than Selegiline and not metabolized to amphetamine
81
What do PTs taking MAO-B Rasagiline need to avoid?
Tyramine containing foods (cheese, meat, beer)
82
MOA of COMT inhibitors?
What are they used for?
What is an adverse event of taking one of these inhibitors?
Prevent dopamine breakdown, more Levodopa avail to cross BBB
Manage motor fluctuations during wearing off effect
Entacapone causes orange urine
83
What are some required step when using COMT Inhibitor Tolcapone?
What must Entacapone be used with?
Used in PTs that failed Entacapone therapy
Reqs PT signed consent due to hepatotoxicity
Monitor LFTs
Carb/Levodopa- does not cross BBB
84
Anticholinergics are most effective for ? Parkinson's Sxs?
These are the DOC for ?
These don't have an effect on ?
Tremors, Rigidity
Drug induced parkinsonism
Tardive dyskinesia
85
What is the NMDA inhibitor used in Parkinson PTs?
What is this beneficial at helping?
What is the major adverse reaction from this drug?
Amantadine- enhances synthesis and release of dopamine. No effect if dopamine release is already at max
Reduces dyskinesia from Levodopa/Dopamine agonists
Livedo reticularis
86
NMDA inhibitor Amantadine was originally developed to treat ?
Nearly all meds in the management of Parkinson's will have ? s/e
Influenza Type A
Hallucinations
87
Tx for Parkinson drug induced hallucinations are removed in what order?
What drugs need to be avoided or they'll increase Parkinson Sxs?
```
Anticholinergics
Amantadine
Selefiline
Dopamine agonist
Levo/Carbidopa
```
Risperdone
Olanzapine
Typical antipsychotics
88
What two drugs can be used for cognitive d/os in Parkinson PTs?
What are the 5 phases of a Tonic-Clonic seizure
Quetiapine
Clozapine
```
Flexion
Extension
Tremor
Clonic
Postictal
```
89
# Define Tonic
Define Clonic
Define Mycoclonic
Flexion/extension
Repetitive jerking movements
Brief jerking movements of entire body or UE
90
What are the 4 situations that a seizure PT may attempt to withdrawal from therapy?
Anticonvulsant meds work in ? three ways?
Seizure free for 2-5yrs
Single seizure type
Normal neuro exam/IQ
Normal EEG w/ meds
Enhance GABA
Dec Glutamate
Modify E+ conduction
91
What drugs are broad spectrum and used for focal and generalized onset seizure?
```
Carbamazepine
Felbamate
Lamotrigine
Levetiracetam
Oxcarbazepine
Phenytoin
Topiramate
Valproate
Zonisamide
```
92
What drugs are narrow spectrum and only used for focal onset seizures?
```
Carbamazepine
Gabapentin
Lacosamide
Oxcarbazepine
Phenobarbital
Phenytoin
Pregabalin
Tigabine
Vigabatrin
Valproate
```
93
What meds are narrow spectrum and only used for absence seizures?
What are the Fast Ca Channel blockers for seizures?
Ethosuximide
Valproate
```
F COP
Fosphenytoin
Carbamazepine
Oxcarbazepine
Phenytoin
```
94
When is Phenytoin used?
What are the adverse effects
What pregnancy category is it?
Status epilepticus in IV/PO form
Sexual dysfunction
Hirsutism
Gingival hyperplasia
Nystagmus
Cat D
95
Phenytoin use will interact w/ ? classes of meds?
What physiological change will alter Phenytoin concentrations in the body?
PO anticoagulants
Contraceptives
Protein concentration
96
What is a prodrug for Phenytoin and used for loading or maintenance dosing in place of Pheytoin?
What is Carbamazepine used for?
Fosphenytoin
Generalized/Partial seizures
Trigeminal neuralgia
Bipolar
97
What does Carbamazepine use for seizures have so many adverse effects?
What are the serious adverse reactions of using this med?
Epoxide intermediate metabolite
Bone marrow suppression
Steven Johnson Syndrome- get HLA-1502 screening prior to use
SIADH
98
What monitoring needs to be done on PTs taking Carbamazepine?
What pregnancy category is it?
What two interactions can increase levels of this med and what med is lowered by Carb?
LFTs and CBC- watch out for aplastic anemia
Cat D
Lamotrigine, Valproic acid- increase epoxide levels
Dec efficacy of OCPs
99
How is Oxcarbazepine different than Carbamazepine?
Who is given this drug?
No epoxide intermediate
PTs that can't tolerate Carbamazepine
100
What is the more common reaction to occur when taking Oxcarbazepine
What adverse effect is similar to Carbamazepine
HypoNa
Reduces efficacy of OCPs
101
What is preferred for seizure maintenance, Carbamazepine or Phenytoin?
What medication is used for seizures that are historically difficult to control?
Carbs
Phenytoin has reputation for causing functional impairment and learning problems
Phenobarbital
102
What are the adverse effects of Phenobarbital?
What interactions does it have?
CYP ETOH
| Reduces OCP efficacy
103
What medication could be added to Carbamazepine or Phenytoin for generalized seizures or essential tremors?
Primidone- s/e same as Phenobarbital
104
What are the two GABA receptor blockers used for seizure?
What are the clinical uses of Gabapentin?
What are the adverse effects?
Phenobarbital
Primidone
Neuropathic pain
Spasmolytic
Diabetic neuropathy
Drowsy/fatigue
Weight gain
105
What med is an adjunct for partial onset seizures?
What else can this drug be used for?
What PT education has to happen?
Pregabalin
Neuropathic pain, RLS, social phobia
Rapid d/c= N/D/Insomnia
106
What is the DOC and 2nd DOC for absence seizures?
What is the MOA of the Valproic acids and derivative?
Ethosuximide- side effect of N/V and needs CBC monitoring
Valproic Acid
Block Ca/Na channels
Inc GABA production
Dec GABA degredation
107
Valproic acid and derivatives are used for ?
What non-epileptic use are they used for?
Non convulsive seizures
Manic episodes of Bipolar
Migraine prophylaxis
108
What is the FDA indication on Valproic Acid?
What are the most common and severe adverse reactions?
Only for replacement PO dosing, sometimes used absence status epilepticus
Alopecia
Platelet aggregation
Weight gain
Liver failure death
109
Valproic acids are Preg Cat D due to their likelihood of causing?
What is used if PT OD's on these meds?
Spina Bifida
Naloxone
110
What is the MOA of Lamotrigine
What unique setting is this used in?
Dec glutamate/aspartate release
Delays repetitive neuron firing
Blocks fast Na channels
Lenox-Gastaut- pediatric onset epilepsy
111
What is the effect of OCPs on Lamotrigine
What is the effect of Valproic Acid on Lamotrigine?
Reduces, inc seizures
Dec Lamotrigine metabolism= inc levels in circulation
112
What is the Black Box warning on Lamotrigine?
What is the MOA of Topiramate?
Steven Johnson Syndrome
Fast Na channel blocker to enhance GABA, antagonize AMP and wakly inhibit carbonic anhydrase
113
What is Topiramate used for?
What is the unique adverse effect of Topiramate?
Adjunct for absence seizures
Lenox-Gastaut
Off label: migraine prophylaxis
Memory impairment
Metabolic acidosis
Encephalopathy- especially w/ Valproic acid
114
Topiramate will interact and decrease what two drugs?
What is Levetiracetam used for?
OCPs and Digoxin
+6y/o idiopathic generalized epilepsy
+12y/o myoclonic seizure
115
Use and Adverse of Ezogabine
Adjunct partial onset seizure
Urine retention/UTI
QTc prolongation
Vision loss
Psychosis
116
Use and Adverse of Lacosamide
Mono/adjunct therapy for partial onset seizure
Prolonged PR interval
AV block
Multi organ hyper sensitivity
Neutropenia
117
Use and adverse of Vigabatrin
Adjunct for refractory complex partial seizures
Mono therapy for infantile spasms
Depression
MRI abnormalities
Vision loss, permanent*
Weight gain
118
Use and adverse of Zonisamide
Adjunct for partial seizures
Bipolar d/o
```
Steven Johnson
Sulfonamide agent
Blood issues
Kidney issues
Hyperhydrosis in kids
No G6PD PTs
```
119
Use and Adverse of Felbamate
Use and Adverse of Tiagabine
Partial seizure
Lennox Gastaut
Aplastic anemia
Liver failure
Adjunct for partial seizures
Steven Johnson
Non-convulsive epilepticus
120
What two drugs can be used to Tx of prolonged febrile seizures?
What meds are used for emergency cases of status epilepticus?
Phenobarbital
Diazepam
Lorazepam- less lipophilic, stays in CNS longer
Diazepam- rectal gel
Midazolam- preferred for IM
121
What are the urgent meds used for Status Epilepticus
Fosphenytoin
Phenytoin- causes arrhythmia, HOTN, extravasation
Phenobarbital
Off label, if PT can't take above 3 meds:
Valproic acid
Levetiracetam
Lacosamide
122
What meds are used for refractory status epilepticus?
Pentobarbital- PT must be on ventilator
Propofol- PT must be on ventilator
Midazolam- HOTN, respiratory depression
123
Which anti-seizure meds need to be used with caution in geriatric PTs and why
What is used for eclampsia Tx and what is used for supplementation?
```
Lamotrigine- dec clearance
Carbamazepine- dec clearance
Phenytoin- dec protein binding
Valproic- dec protein binding
Diazepam- inc t1/2
```
Mg sulfate
Folic Acid- prevent neural tube defects
124
What two anti-convuslant meds are not effected by/or cause dec efficacy of birth control?
What birth defects can occur due to Phenytoin, Carbamazepine, Phenobarbital, Valproic acid or Topiramate use during pregnancy?
Medroxyprogesterone
Levonorgesterol
```
Phenytoin: cleft palate, poor cognitive function
Carbamazepine: posterior cleft palate
Pheno: cardiac and cognitive issues
Val: congenital malformation
Top: congenital malformation
```
125
What 6 anticonvulsants cause the worse sexual dysfunction?
What two cause the least?
Carb Phenobarb Pheny Pregablain Top Zoni
Lamo Oxcar
126
What are three issues seen w/ anticonvulsant class usage?
What causes the negative sxs of schizophrenia?
Sex dysfunction
Osteopenia
SI
Flat affect, Apathy due to inhibited mesocortical path in prefrontal cortex= no dopamine
127
What causes the Positive Sxs of Schizophrenia?
What causes the adverse effects of Schizophrenia?
Delusion, Hallucination from dysfunction in the mesolimbic pathway= uninhibited dopamine release
Parkinsonism, dysfunction in nigrostriatal pathway in corpus striatum= inhibited dopamine release causing inhibited ACh
128
What are the top NTs involved in psychological abnormalities?
Dopamine
Serotonin
Glutamate
129
What are the typical antipsychotics?
```
Chlorpromazine
Fluphenazine
Haloperidol
Loxapine
Mesoridazine
Perphenazine
Thioridazine
Thiothixene
Trigloperazine
```
130
What are the atypical antipsychotics
```
Aripiprazole
Asenapine
Clozapine
Illoperidone
Lurasidone
Olanzapine
Paliperidone
Quetiapine
Risperidone
```
131
What class of anti-psych is recommended to be used first when Dx of Schizo has been given?
How long can it take for max treatment response to occur w/ these drugs?
Second unless PT prefers or has had success w/ typicals before
6mon
132
What is the only FDA approved drug for hiccups?
Which anti-psych is most widely used w/ an anti-emetic effect?
Chlorpromazine- may cause pigment deposits in retina/cornea
Prochlorperazine
133
What is the most common EPS Sx from using antipsych meds?
What is a common s/e from using antipsychotics that affects men and women?
Akathesia
Tx w/ Propanolol
Anorgasmia
134
What is the black box warning on anti-psychs?
What is the MOA of 1st Gen anti-psychs?
Inc mortality in elderly PTs w/ dementia related psychosis
Competitively blocks dopamine receptors in, less effective at controlling negative Sxs of Schizo
135
What is the difference between Low Potency and High Potency typical anti-psychs?
Low: low affinity for dopamine receptors, less risk of EPS.
Higher adverse reactions
High: higher affinity for dopamine receptors, less adverse reactions
136
If Schizo PT is having pseudo-parkinsonism Sxs due to drugs, what can be given for Tx?
What are the adverse effects of typical anti-psychs?
Anticholinergic: Trihexyphenidyl or Benztropine
Antihistamine: Diphenhydramine
```
QTC prolongation
OHOTN
Weight gain
Anticholinergic
Sedation
```
137
# Define Neuorleptic Malignant Syndrome
What other major s/e is seen w/ typical anti-psych use?
Common w/ high potency typical anti-psychs, most severe adverse drug event
Prolactin elevation
F: galactorrhea, menstrual irregularity
M: gynecomastia, sex dysfunction
138
What are the low potency typical anti-psychs?
What are the high potency typicals?
Chlorpromazine
Thioridazine
Haloperidol
Fluphenazine
Trifluperazine
139
Low Potency: Thioridazine
High anticholinergic effect
Highest occurrence of sedation
BBW: Torsades
140
High Potency: Trifluoperazine
General non-psychotic anxiety used after Benzos
| Long term use= tardive dyskinesia
141
High Potency: Fluphenazine
IM long lasting neuroplastic therapy (PT refusing PO meds)
| Reqs bridging meds
142
High Potency: Haloperidol
Schizo, Agitation, Tourettes
IM lasts 1mon
IV= Torsades induction
Severe EPS
QTc prolongation
C/i: Parkinsons, CNS depression, comatose PT
143
2nd Gen anti-psychs are dopamine antagonists and block 5HT receptors except for ? drug
These have a similar efficacy for positive Sxs except for which one?
Aripiprazole
Clozapine
144
What is an adverse effect of taking atypical anti-psychs?
What three things are monitored in PTs taking atypicals?
Metabolic Syndrome- waist circumference taken at baseline
Weight
Hyperglycemia/DM
Lipids
145
What two atypicals are more likely to cause weight gain?
Which one causes the least?
Clozapine
Olanzapine
Lurasidone
146
Atypical Antipsych: Clozapine
This is the only atypical that provides what benefit?
Most effective
Reserved for 3x failures and resistant to other antipsychs
Reduce risk of suicide
Better improvement of negative Sxs
147
What is the BBW on Clozapine
What monitoring is done?
Agranulocytosis
Weekly CBC fist 6mon the Q2wks
148
Why would Olanzapine be preferred over Clozapine?
Olonzapine can also be used in MDD if it's combined w/ ?
No agranylocytosis risk
Fluoxetine
149
What monitoring is done for Olanzapine?
What is the benefit of using Risperidone?
Monitor for respiratory depression x 3hrs after administration
More effective against positive Sxs
150
What is the adverse effect of using Risperidone?
Why would you chose Paliperidone over Risperidone?
Most prolactin elevation of all the atypicals
Highest EPS of all atypicals
Pal: IM Q3mon, lower EPS/hyperprolactinemia
151
Which atypical med has a risk of causing cataracts?
What is the advantage and disadvantage of using Ziprasidone?
Quetiapine- psychosis in Parkinson's PTs
Lower metabolic syndrome risk
Higher QTc prolongation
152
Which atypical can NOT be used in depression?
This med is only available in ? form
Asenapine
Sublingual tablet
153
Which atypical is ONLY used for Schizo?
What are the down sides?
Iloperidone
Higher OHOTN and QTc prolongation w/ BID dosing
154
What are the perks of taking Lurasidone?
When would using this one be preferred?
Low s/e except medium sedation
Weight management, can't afford any more weight gain
155
What meds are high potency a/typicals and benzos that can be used for acute agitation and psychosis?
Haloperidol
Diazepam/Lorazepam
Midazolam
Atypical: Olanzapine, Ziprasidone
156
Antipsychotics that are PO disintegrating?
Which ones are used in parenteral formulation?
Risperidone
Olanzapine
Ziprasidone
Olanzapine
157
What antipsychotics are used as rapid tranquilizers?
Which ones are reserved for non-compliant PTs or for maintenance?
```
Chlorpromazine
Fluphenazine
Haloperidol
Ziprasidone
Olanzapine
```
Haloperidol decanoate
Fluphenazine deconate
Risperidone, long acting
Paliperidone
158
Why are Benzos and Barbituates better at sedating than natural GABA?
Which ones are linear w/ inc concentration up to death?
Different binding sites but same sites as ETOH
Barbituates
159
What are the short acting Barbituates?
What barbituate is the DOC for seizures?
```
SPAM
Secobarbital
Pentobarbital
Amobarbital
Methohexital
```
Phenobarbital
160
Which barbituate is a combo of 4 drugs used as an adjunct in IBS Tx?
What are the adverse effects of barbituates?
Donnatal
COW
CNS depression
OD
Withdrawal, worse than opiates
161
What is Methohexital used for?
What is Pentobarbital used for?
Which ones can be used for insomnia?
Anesthesia induction/maintenance
Status epilepticus
Pento Amobarbital Seco Thiopental
162
Short acting Benzos
Intermediate Benzos
Long acting Benzos
Clorazepate- prodrug
Triazolam
Oxazepam
Midazolam
Temazepam
Estazolam
Alprazolam
Lorazepam
```
Chlonazepam
Diazepam
Chlordiazepoxide
Flurazepam
Quazepam
```
163
Which class of benzos causes rapid tolerance and commonly have PTs go through withdrawal?
Where do benzos exert their effects?
Short half-life
Central action causing relaxation, no analgesic property
164
Which benzo is preferred in PTs w/ liver Dz?
Which benzos can be used for anxiety?
Lorazepam
Clonazepam
Lorazepam
Diazepam
165
What benzos can be used for panic attacks?
Which ones can be used for alcohol withdrawal?
Clonzaepam
Alprazolam
Oxazepam
Chlordiazepoxide
Oxazepam
Lorazepam*
Diazepam
166
Which benzos interact w/ CYP3A4 the least?
These same 3 drugs are preferred in ? PT population?
Lorazepam
Oxazepam
Temazepam
Geriatrics
167
What is the benzo OD rescue agent?
What medication is used as a second line agent for anxiety when benzos need to be avoided?
Flumazenil
Buspirone
168
How does Zolpidem exert its effect?
What are the s/e of Eszopiclone?
Acts on benzo receptor enhancing GABA
Metalic taste
SIs
169
Which hypnotic is least likely to cause daytime somnolence?
MOA of Suvorexant
Zaleplon
Orexin receptor agonist
170
What is Ramelteon MOA
How effective is this?
Melatonin receptor agonist
Improves sleep by 7min
171
What is Tasimelteon used for?
What short, intermediate and long acting Benzos are used for insominia?
Melatonin receptor agonist for non-24hr sleep/wake d/o (blind PTs)
Short: Triazolam
Inter: Temazepam, Estazolam
Long: Flurazaepam, Quazepam
172
Which antidepressants are sedating?
What antihistamines can be used for insomnia but who must use caution when using?
Doxepin
Mirtazapine
Trazadone
Diphenhydramine
Doxylamine
Elderly- worsened dementia and BPH
