Pharmacology- Neuro Flashcards
What are some first generation AEDs??
Phenobarbital
phenytoin
primidone
ethosuximide
diazepam
lorazepam
carbamazepine
Valproic acid, divalproex
What are considered broad spectrum, second generation AEDs?
Lamotrigine
levetiracetam
oxcarbazepine
Zonisamide
broad spectrum AED medications means?
They can be used for generalized and focal seizures
Benefits of 2nd generation AEDs?
they are equally as effective as first generation AEDs
they are considered clean drugs- less drug interactions, less symptoms
what are some very important second generation AED medications?
Gabapentin
lamotrigine
levetiracetam
oxcabazepine
zonasimide
What are some things to think about when choosing an AED?
seizure type(most important)
mechanism of action
pharmacokinetics
concomitant medical/psychiatric conditions
adverse side effects
cost
Why is it important to know the seizure type?
picking the wrong drug can cause seizure to get worse
What are some first line medications for focal seizures, either impaired aware, with or without secondary generalization)
Carbamazepine- MOST common
lamotragine
levetiracetam
oxcarbazepine
perampanel
what are some medications that are first line for ELDERLY patients w/ focal aware or impaired awareness (partial seizures)
Lamotrigine
gabapentin
what is first line treatment for non-motor (Absence)
Ethosuximide
Divalproex
what are alternative or add-on therapies that should be considered for Absence seizures
Clonazepam
lamotrigine
levetiracetam
zonisamide
What is first line treatment for Tonic Clonic seizures?
Divalproex
lamotrigine
levetiracetam
* broad spectrum medication*
what is first line treatment for generalized onset motor (atonic or myoclonic)
Divalproex
lamotrigine
levetriacetam
First line treatment for status epilepticus (*medical emergerncy)
1st. IV/IM/BZD
(diazempam, lorazepam, or midazolam)
OR rectal diazepam (very fast onset)
2nd. IV Fosphenytoin
Alternative line treatment for status epilepticus (*medical emergerncy)
IV phernobarbital
first line medication for Infantile spasms (may be focalized or generalized onset epileptic spasms)
vigabatrin
What is the mechanism of seizures
seizures are a mismatch of excitation and inhibition
what is the culprit of excitation in seizures?
glutamate
AEDs for seizures often target?
glutamate or GABA
what helps to provide inhibition
Gaba
A majority of AEDs block what?
Sodium
What are possible mechanisms of actions for AEDs to decrease excitation
-inhibit voltage gated Na+ channels to prevent release of neurotransmitters
-inhibit voltage-gated Ca2+ channels to prevent release of neurotransmitters
-inhiber neurotransmitter release by binding to SV2A
-antagonize glutamate activity at receptor sites
what are the possible mechanisms of actions for AEDS to increase inhibtion
-enhance GABA action by increasing concentration (block reuptake, block metabolism)
-enhance GABA action by modulating GABA receptor mediated Cl- current
-activation of K+ channels by ezogabine
what AEDs are sodium channel blockers
phenytoin
carbamazepine
oxcarbazepine
lamotrigine
lacosamide
rufinamide
what AEDs are glutamate receptor blockers
topiramate
zonisamide
what AEDs are GABA enhancers?
Benzodiazepines
barbituates
valproic acid
vigabatrin
tiagabine
Something to know about Lamotrigine
Must start with low dose and titrate slowly to avoid steven johnsons syndrome
which AEDs are CYP enzyme inducers? What does that mean?
carbamazepine
oxcarbazepine
phenobarbital
pheytoin
topiramate
* lower concentration of other drugs- causing failure
Which AEDs are CYP inhibitors? what does that mean?
Oxcabazepine
topiramate
valproic acid
* may inhibit enzyme causing toxicity.
which medications put you at risk for stevens-johnson syndrome?
Carbamazepine, lamotrigine (TOP TWO)
Levetiracetam, phenytoin, zonisamide
what is the first line treatment for tension-type headache? what should you keep in mind?
Over the counter NSAIDs and Acetaminophen as needed
* medication overuse headache may superimpose if treatment is used too often
what are non-specific treatments of migraines- specific treatments? who is this medication for?
Triptans
ergotamines
which medications are triptans?
sumatriptan
rizatriptan
zomiitriptan
how do you pick which triptan to prescribe?
consider migraine attack duration? Longer lasting attack may be treated better with a longer half life
if patient is vomiting- choose non-oral formulation may be better
rapid onset attacks may benefit from nasal/subcutaneous route
which medication is an ergotamine?
dihydroergotamine
MOA: selective 5-hydroxtryptamine, serotonin (5-HT) agonists
triptans
5-HT receptor agonist. Non-oral treatment that is available in intra-nasal, injectable and IV forumulations
Dihydroergotamine
which medications are anti-emetic medications?
ondansetron
metoclopramide, prochlorperazine, promethazine
antiemetics such as metoclopramide, procholorperazine and promethazine need to be used with benadryl… why?
to reduce the risk of extrapyramidal side effects
what is the MOA of metoclopramide and procholoperazine?
dopamine receptor blocker
promethazine has what mechanism of action?
H1 receptor blocker and weak dopamine antagonist
what treatments are used for cluster headache?
-inhaled oxygen
-subcutaneous imitrex
what classes of medications can be used for headache prevention?
Antiepileptic drugs
antidepressant drugs
beta-blockers
calcium-channel blockers
what is widely used as a first line preventative (mostly for migraine)
topiramate
which medication is highly terotogenic, so it is not give to reproductive age females?
valproate
what antidepressants can be used as preventative treatments for headache?
amitriptyline and other tricyclic antidepressants (star at lower dose)
venlafaxine ( very good for migraine prevention; start at lower dose)
Beta-blockers are often a great option for long-term prevention of migraines. What medication is a beta-blocker?
propranolol
what is considered the treatment of choice for cluster headaches
verapamil
what are preventative treatments for tension type headache?
amitriptyline
venlafaxine
what is a good alternative to verapamil used for cluster headaches when the patient has shorter active cluster periods?
glucocorticoids (prednisone, etc)
What is the preferred treatment Guillain-Barre syndrome?
plasma exchange (removes antibodies from the blood)
IVIG (intravenouse immuge globulin)
what medication could you prescribe for bell’s palsy patients?
steroids (prednisone) to reduce inflammation are associated with good facial functional recovery
*antiviral medications
what are treatment options for myasthenia gravis?
Treatment is acetylcholinesterase inhibitors, immunosuppressants or thymectomy
what is the preferred treatment option for acute attacks in a patient with MS?
glucocorticoids (for functionally disabling symptoms associated with relapse)
How is methylprednisolone used for MS care
it is used as IV short course to shorten the recovery time from moderate to severe relapses
what are some adverse reactions seen from the use of methylprednisolone?
mental status changes
increased infection
fracture risk
what is a form of platform injection therapy
interferon beta
which drug decreases inflammation in the CNS by preventing inflammatory leukocytes from entering the CNS?
It also decreases the number of lesions found on MRI
Interferon Beta
what are are some adverse reactions the treatment with interferon beta?
injection site necrosis
flue like sxs
liver dysfunction
development of neutralizing antibodies
what is a platform injection therapy?
Glatiramer acetate
which drug is a synthetic protein that mimics the structure of myelin, blocking the damaging T cell.
it also decreases inflammation, working primarily inside the CNS to promote anti-inflammatory activity
glatiramer acetate
what drugs are considered monoclonal antibodies?
natalizumab & mixoantrone
which drug blocks the molecular pathway involving cell adhesion that draws the lymphocytes into the CNS
natalizulamab
which drug is antineoplastic agent that supresses the activity of T cells, B cells and macrophages that lead the attack on myelin
mitoxantrone
What should you know about monoclonal antibodies as therapy of MS?
- both of these have high side effect profiles and serious safety issues
-also the highest efficacy therapy
what is the first line treatment of essential tremor? What class of drug is it?
Propranolol
beta blocker
What is another medication treatment alternative for essential tremor?
Primidone(2nd line)
topiramate (3rd line)
gabapentin (4th line)
anticonvulsants
- clonazepam and alprazolam- benzodiazepam (4th line)
what are other treatment options for essential tremor?
occupational therapy
assistive devices
deep brain stimulation
MRI guided focused ultrasound
what are the treatment options for restless leg syndrome
Iron supplementation
eliminate/replace offending medications
dopamine agonists (pramipexole, ropinirole)
carbidopa-levodopa
gabapentin
what is the gold standard for treating Parkinson’s disorder?
carbidopa/levodopa
what are positives and negatives of carbidopa/levodopa
positives: effectively controls motor symptoms
negatives: short half life- eventually the effectiveness decreases, so timing between doses shortens
what side effects standout with Carbidopa/levodopa?
dyskinesia- (often times due to overmedication)
motor fluctuations
What drug can you give with carbidopa/levodopa to help with dyskinesia?
amantadine
when would you use amantadine as a monotherapy for parkinson’s?
In early disease course and when tremor is the predominant symptom
what drug can you give with carbidopa/levodopa to help with motor fluctuations?
COMT inhibitors (Entacapone, Tolcapone)
What option can you give a patient who needs a COMT inhibitor and carbidopa/levodopa?
stalevo (combined pill of Carbidopa/levodopa and Entacapone)
what is the benefit of COMT inhibitors
Extends the life of levodopa by stopping the breakdown of levodopa before it reaches the brain
why can’t you use a COMT inhibitor by itself?
it has no no benefit as a monotherapy
which medications are dopamine agonists?
pramipexole
ropinirole
rotigitine
bromocriptine
what is a side effect that is very concerning with dopamine agonists?
Impulse control issues
* pathological gambling, compulsive eating, compulsive shopping, hypersexuality
what is often a first line treatment for mild symptoms of parkinson’s?
MAO-B inhibitors
which drug class breaksdown dopamine by monoamine oxidase B
MAO-B inhibitors
what drugs are MAO-B inhibitors
Rasagiline
selegiline
what is the benefit of using MOA-B inhibitors with carbidopa/ levodopa?
prolongs the effectiveness of dopamine, so improves motor fluctuations
what drugs are anticholinergics?
trihexyphenidyl
benzotropine
when is the use of anticholinergics beneficial? when should you not use it?
can be useful in younger patients with tremor predominant disease OR in more advanced cases where tremor is still present despite other treatments
Avoid- in the elderly-confusion, hallucinations
what are nonmedical treatments for parkinson’s
physical therapy and occupational therapy
exercise like rock steady therapy
surgical treatments like ablative surgery, deep brain stimulation
what medication should always be given to treat gram positive bacterial meningitis ?
ceftriaxone
what else can be given to treat gram-positive infections?
vancomycin
