Psych, Parkinson drugs Flashcards

1
Q

MAOI SE’s

A
  • Isocarboxazid
  • Phenelzine
  • Tranylcypromine
  • Selegiline
  • Drowsiness
  • Orthostatic hypotension
  • Blurred vision
  • Dry mouth
  • Dysuria
  • Constipation

Serotonin syndrome
• MAO inhibitor + serotonergic agent such as SSRIs, SNRIs or TCAs or meperidine, may result in a life-threatening serotonin syndrome (hyperthermia, muscle rigidity and myoclonus)
• Serotonin syndrome results from overstimulation of 5-HT1A and 5-HT2 receptors.
• An irreversible MAO inhibitor with a serotonergic agent is the most toxic reported combination.

THE CHEESE REACTION
• Tyramine is contained in certain foods, such as aged cheeses, chicken liver, soy products, pickled fish and red wines.
• Tyramine is normally inactivated by MAO in the gut.
• Patients on an MAO inhibitor cannot degrade tyramine.
• Tyramine causes release of catecholamines resulting in tachycardia, hypertension, arrhythmias, seizures, and possibly, stroke.
• Sympathomimetic drugs may also cause significant hypertension when combined with an MAO inhibitor.
• OTC cold preparations that contain pseudoephedrine and phenylpropanolamine are contraindicated in patients taking MAO inhibitors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

TCAs

A

• Amitriptyline, Clomipramine, Desipramine, Imipramine, Nortriptyline

  • There is variability in affinity for SERT versus NET.
  • For example, clomipramine has very little affinity for NET but potently binds SERT.
  • On the other hand, desipramine and nortriptyline are more selective for NET.
  • Additionally,TCAs block α-adrenergic, muscarinic, histamine and 5-HT receptors.
  • Blockade of these receptors are responsible for many of the adverse effects of the TCAs.

SE’s
• TCAs slow cardiac conduction similarly to quinidine, which may precipitate arrhythmias.
• Blockade of α1-adrenoceptors causes orthostatic hypotension and reflex tachycardia. Most serious problem in the elderly.
• H1 blockade causes sedation and weight gain.
• Sexual effects are common, particularly with highly serotonergic agents such as clomipramine.
• The TCAs have a narrow therapeutic index.
• Depressed patients who are suicidal should be given only limited quantities of these drugs and be monitored closely.

  • Overdose of TCAs can induce lethal arrhythmias.
  • Treatment includes cardiac monitoring, airway support and gastric lavage.
  • Sodium bicarbonate is useful in reversing conduction block.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

SSRI’s

A

• Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline

  • SSRIs have little blocking activity at muscarinic, α-adrenergic, and histaminic H1 receptors.
  • Adverse effects associated with TCAs, such as orthostatic hypotension, sedation, dry mouth, and blurred vision, are not seen with the SSRIs.

USES
• SSRIs are the drugs of choice in treating depression.
• OCD, PD, GAD, PTSD, SAD, PMDD, bulimia

SEs
• Increased serotonergic activity in the gut is associated with nausea, GI upset and diarrhea.
• Increased serotonergic tone at the level of the spinal cord and above is associated with diminished sexual function and interest.
• Some patients gain weight when taking SSRIs, particularly paroxetine.
• Fatality rate is low. Overdoses may cause seizures.

DRUG INTERACTIONS
• Fluoxetine and paroxetine inhibit CYP2D6: high potential for drug interactions.
• Fluvoxamine inhibits CYP1A2, CYP2C19 and CYP3A4: high potential for drug interactions.
• Citalopram, escitalopram and sertraline have low potential for interactions.
• All SSR Is have the potential to cause a serotonin syndrome when used in the presence of a MAO inhibitor or another serotonergic drug.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

SNRI’s

A
  • Venlafaxine, Duloxetine
  • Differ from TCAs by their lack of blockade of H1, muscarinic and α1 receptors.
  • May be effective in treating depression in patients in whom SSRIs are ineffective.

Venlafaxine
• Potent inhibitor of 5HT uptake.
• At higher doses inhibits norepinephrine uptake.
• Also inhibits reuptake of dopamine very weakly.

Duloxetine
• Inhibits serotonin and norepinephrine reuptake at all doses.

DRUG INTERACTIONS
• SNRIs have relatively fewer CYP450 interactions than the SSRIs.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

NDRI’s

A

Bupropion
• Inhibits norepinephrine and dopamine uptake.
• Increases norepinephrine and dopamine release.
• Not associated with sexual dysfunction problems which occur with SSRIs because it lacks the serotonergic component.
• Bupropion is associated with seizures in overdose.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

SARI’s

A
  • Nefazodone, Trazodone
  • When 5HT reuptake is blocked by SSRIs, all 5HT receptors are stimulated by increase in 5HT.
  • Stimulation of 5HT1A receptors in raphe may help depression.
  • But stimulation of 5HT2 receptors in forebrain may cause agitation or anxiety, and stimulation of 5HT2 receptors in spinal cord may cause sexual dysfunction.
  • SARIs combine 5HT reuptake blockade with 5HT2 antagonism
  • This decreases undesired actions of stimulation of 5HT2 receptors.
  • The main action of both nefazodone and trazodone is blockade of the 5-HT2A receptor.
  • Inhibition of this receptor is associated with antianxiety, antipsychotic, and antidepressant effects.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Nefazadone

A

• Nefazodone is a weak inhibitor of SERT and NET and a potent antagonist of 5-HT2A.
• Nefazodone has been associated with
hepatotoxicity.
• Nefazodone is no longer commonly prescribed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Trazodone

A
  • Trazodone is a weak inhibitor of SERT.
  • Primary metabolite is a potent 5-HT2 antagonist.
  • Trazodone also blocks α1 and H1 receptors.
  • Extremely sedating.
  • Excellent hypnotic.
  • The main use of trazodone is as hypnotic.
  • Rare but troublesome side-effect: priapism.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Mirtazapine

A
  • NASSA. Antagonist of central presynaptic α2 receptors: enhances release of norepinephrine and 5-HT.
  • Antagonist at 5-HT2 and 5-HT3 receptors.
  • H1 antagonist, which is associated with sedation and weight gain.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Lithium

A
  • Used prophylactically in treating manic- depressive patients and in treatment of manic episodes.
  • Also effective in 60-80% patients with mania and hypomania
  • The inositol depletion theory is the most widely accepted explanation for the actions of lithium.
  • G protein-linked receptors coupled to Gq activate PLC, which cleaves PIP2 to yield DAG and IP3.
  • IP3 signaling is terminated by conversion to IP2.
  • IP2 is converted to IP1 by inositol polyphosphatase.
  • IP1 is converted to inositol by inositol monophosphatase.
  • Lithium inhibits inositol polyphosphatase and monophosphatase, thus blocking the regeneration of inositol.
  • Free inositol is essential for the synthesis of PIP2, therefore lithium blocks the phosphatidylinositol signaling cascade in the brain.
  • Inositol circulates freely in blood, but it cannot cross the blood-brain barrier.
  • The two mechanisms of inositol synthesis in CNS neurons: regeneration from IP3 and de novo synthesis from glucose-6-phosphate, are inhibited by lithium.
  • By blocking the regeneration of PIP2, lithium inhibits central adrenergic, muscarinic, and serotonergic neurotransmission.
  • Inhibition by lithium is uncompetitive.
  • This means that only neurons with active receptors will be affected by lithium.

SEs
• Lithium has a narrow therapeutic window.
• Acute lithium toxicity results in neurological effects, progressing from confusion and motor impairment, to coma, convulsions and death if the plasma concentration reaches 3 – 5 mM.
• Adverse neurologic effects of lithium include tremor, sedation, ataxia, and aphasia.
• The use of lithium during pregnancy may increase the incidence of congenital cardiac anomalies. Category D.
• Contraindicated in nursing mothers.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Alternatives to lithium

A

• The antiepileptics valproate and carbamazepine are widely used.

Other alternatives:
• Atypical antipsychotics: olanzapine, aripiprazole, quetiapine, risperidone & ziprasidone.
• Antiepileptics: lamotrigine.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q
  • Chlorpromazine
  • Haloperidol
  • Fluphenazine
  • Thioridazine
A
  • Classical antipsychotics are subclassified according to their potency:
  • High-potency drugs: Fluphenazine and haloperidol. More likely to produce EPRs.
  • Low-potency drugs: Chlorpromazine and thioridazine. Less likely to produce EPRs and more likely to produce sedation and postural hypotension.

• The efficacy of the traditional neuroleptic drugs correlates closely with their ability to block D2 receptors in the mesolimbic pathway.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q
  • Clozapine
  • Risperidone
  • Olanzapine
  • Quetiapine
  • Ziprasidone
  • Aripiprazole
  • Paliperidone
A

ATYPICAL ANTIPSYCHOTIC DRUGS
• Atypical antipsychotic drugs have higher affinities for other receptors than for the D2 receptor. For example:
• Clozapine has high affinity for D1, D4, 5HT2, muscarinic and a-adrenergic receptor, but it is also a D2 blocker.
• Risperidone blocks 5HT2 to a greater extent than it does D2.

  • Dual antagonism at 5-HT2A and D2 receptors.
  • Part of their action is due to 5HT receptor blockade.
  • Less likely to cause EPRs than classical agents.
  • Less likely to cause tardive dyskinesia
  • Less likely to cause increases in prolactin
  • More effective at treating negative symptoms.
  • Effective in refractory populations.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

ACTIONS OF ANTIPSYCHOTIC DRUGS

A
  • ANTIPSYCHOTIC
  • ANTIEMETIC
ANTIPSYCHOTIC ACTIONS
• Reduce hallucinations and agitation. 
• Have a calming effect.
• Do not depress intellectual function. 
• Motor incoordination is minimal.
• Onset of antipsychotic action is ≤24h.
  • With the exception of aripiprazole and thioridazine, most neuroleptics have antiemetic effects.
  • Mediated by blockade of D2 receptors of the chemoreceptor trigger zone of the medulla.
  • Most antipsychotic drugs are almost completely metabolized, mainly by CYP2D6, CYP1A2 and CYP3A4.
  • Antipsychotics do not interfere with the metabolism of other drugs.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Flumazenil

A
  • Flumazenil: blocks actions of benzodiazepines.
  • Only benzodiazepine receptor antagonist available for clinical use.
  • Approved for reversing the CNS depressant effects of benzodiazepine overdose and to hasten recovery following use of these drugs in anesthetic and diagnostic procedures.
  • Rapid onset.
  • Short duration: half-life about 1 hour, due to rapid hepatic clearance.
  • Frequent administration may be necessary to maintain reversal of long-acting benzodiazepines.
  • May precipitate withdrawal in physiologically dependent patients or may cause seizures if a benzodiazepine is used to control seizures.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Barbituates

A
  • Barbiturates induce tolerance, drug-metabolizing enzymes, physical dependence and cause very severe withdrawal symptoms.
  • They can cause coma in high doses.
  • Barbiturates also act on GABAA receptors, and enhance GABAergic transmission.
  • The binding site of barbiturates is different from that of the benzodiazepines.
  • Barbiturates increase the duration of the GABA- gated chloride channel openings.
  • Barbiturates can also block glutamate receptors and sodium channels.
  • The multiplicity of sites of action of barbiturates may explain their ability to induce full surgical anesthesia and their more pronounced central depressant effects.

Respiratory depression
• Barbiturates suppress the hypoxic and chemoreceptor response to CO2. Overdosage causes respiratory depression and death.

Enzyme induction
• Barbiturates induce liver cytochrome P450 enzymes.

Anesthesia
• Ultra short acting barbiturates, such as thiopental are used IV to induce anesthesia.

Anticonvulsant
• Phenobarbital is used in long-term management of tonic-clonic seizures, status epilepticus and eclampsia.

Anxiety
• Replaced by benzodiazepines.

Hepatic Metabolic Uses
• Phenobarbital has been used to treat hyperbilirubinemia and kernicterus in the neonate.
• The nondepressant barbiturate N-phenylbarbital works equally well.

  • CNS: drowsiness, impaired concentration, mental and physical sluggishness.
  • Paradoxical excitement
  • Hypersensitivity
  • Hangover
  • Barbiturates increase porphyrin synthesis: contraindicated in patients with porphyria.
  • In the presence of pulmonary insufficiency they may cause serious respiratory depression.
  • Rapid IV injection of a barbiturate may cause cardiovascular collapse.
  • Pain: May worsen perception of pain.
  • Addiction: severe withdrawal syndrome.
  • Poisoning: severe respiratory depression and central CV depression.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

NON-BENZODIAZEPINE BENZODIAZEPINE RECEPTOR AGONISTS

A

• These drugs act only on the BZ1 subtype of benzodiazepine receptors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Zolpidem

A
  • Hypnotic. Short duration of action.
  • Short half life = 1.5 - 3.5 h.
  • Indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation.
  • Minimal muscle relaxing and anticonvulsant effects.
  • Little or no tolerance.
  • Low incidence of adverse effects.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Zaleplon

A
  • Rapid onset and very short duration of action.
  • Elimination half life = 1 h.
  • Indicated for the short-term treatment of insomnia.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Eszopiclone

A
  • (S)-Entantiomer of zopiclone.
  • Pharmacologically active enantiomer of zopiclone.
  • Approved for treatment of insomnia.
  • Decreases sleep latency and improves sleep maintenance.
  • Half-life = 6 hours.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

BUSPIRONE

A

• No hypnotic, anticonvulsant or muscle relaxant properties.
• Only anxiolytic.
• Indicated for management of anxiety
disorders.
• Onset: 2 - 3 weeks.
• Mechanism of action may be analogous to antidepressants.

Advantages:
• Less psychomotor impairment than BZ.
• No drug interactions with EtOH
• No drug interactions with benzodiazepines and other sedative-hypnotics
• No rebound anxiety or withdrawal signs on abrupt discontinuance
• No dependence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Ramelteon

A
  • Agonist at MT1 & MT2 melatonin receptors.

* Indicated for the treatment of insomnia characterized by difficulty with sleep onset.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Hydroxyzine

A
  • Antihistamine with antiemetic activity.
  • Approved for symptomatic relief of anxiety.
  • Nonprescription antihistamines with sedating properties, such as diphenhydramine and doxylamine, are effective in treating mild types of insomnia.
  • However, these drugs are usually ineffective for all but the milder forms of situational insomnia.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Propranolol

A
  • Widely used to control performance anxiety.

* Clonidine may also modify autonomic expression of anxiety.

25
Q

Levodopa

A

• Levorotatory stereoisomer of dopa. Metabolic precursor of dopamine (and norepinephrine).

  • Effect of levodopa decreases as fewer cells are capable of taking up levodopa and converting it to dopamine over time
  • Consequently, motor control fluctuation develops.
  • Relief provided by levodopa is only symptomatic and lasts only while the drug is present in the body.

MECHANISM OF ACTION
• Dopamine does not cross the blood-brain barrier.
• Levodopa is transported into the CNS and converted to dopamine in the brain.
• Much of the drug is decarboxylated to dopamine in the periphery.
• This results in peripheral side effects (nausea, vomiting, cardiac arrhythmias, hypotension).

  • Levodopa is absorbed rapidly from the small intestine.
  • Food delays the appearance of levodopa in the plasma.
  • Certain amino acids can compete with the drug for absorption from the gut and for transport from the blood to the brain.
26
Q

Carbidopa

A
  • Carbidopa is a dopa decarboxylase inhibitor that does not cross the blood-brain barrier.
  • Levodopa is given in combination with carbidopa.
  • Carbidopa decreases the metabolism of levodopa in the GI tract and peripheral tissues, thus increasing the availability of levodopa to the CNS.
  • Sinemet is a dopa preparation containing carbidopa and levodopa in fixed proportion (1:10 or 1:4).
  • Levodopa/carbidopa is an efficacious drug regimen for PD.
  • There is a decline in response during the 3rd to 5th year of therapy.
  • Levodopa does not stop the progression of PD, but early initiation of levodopa therapy lowers mortality due to the disease.
27
Q

Fluctuations in Levodopa response

A

Wearing-Off Reactions (End-Of-Dose Akinesia)
• Fluctuations related to the timing of levodopa intake.

The On-Off Phenomenon
• Fluctuations in response unrelated to the timing of doses.
• The exact mechanism is unknown.
• For patients with severe off-periods who are unresponsive to other measures, apomorphine SC may provide benefit.

28
Q

Levodopa interactions and CI

A
  • Vitamin B6 is a cofactor for Dopa decarboxylase: it increases peripheral metabolism of levodopa
  • Concomitant administration of nonspecific MAO inhibitors, may precipitate hypertensive crisis.
  • Levodopa should not be given to psychotic patients, as it may exacerbate the mental disturbance.

CI
• Levodopa is contraindicated in angle-closure glaucoma.
• Cardiac patients should be carefully monitored because of possible arrhythmias.
• Antipsychotic drugs are contraindicated in PD: they may produce a parkinsonian syndrome.

29
Q

Bromocriptine

A
  • Ergot D2 agonist.
  • Little response in patients who do not respond to levodopa.
  • Often used with levodopa in patients responding to drug therapy.
SE's
• GI Effects
• Cardiovascular Effects
• Dyskinesias
• Mental Disturbances

Miscellaneous Adverse Effects:
• Pulmonary infiltrates
• Pleural and retroperitoneal fibrosis
• Erythromelalgia

30
Q

Pramipexole, Ropinirole

A
  • Nonergot dopamine agonist. Better adverse effect profile.
  • Well tolerated.
  • They are used increasingly as initial treatment for PD rather than as adjuncts to levodopa.
  • Particularly for younger patients.
  • Older patients are more vulnerable to the adverse cognitive effects of the dopamine agonists.
31
Q

Rotigotine

A
  • Nonergot dopamine agonist. Available in a transdermal formulation.
  • Once-daily use.
32
Q

Apomorphine

A
  • Nonergot dopamine agonist. Rescue therapy for treatment of “off” episodes of akinesia in patients on dopaminergic therapy.
  • Emetogenic; pretreatment with the antiemetic trimethobenzamide is recommended.
  • Other adverse effects: QT prolongation, dyskinesias, drowsiness, sweating, hypotension and bruising at the injection site.
33
Q

Deprenyl (Selegiline)

A
  • MAOI. Selectively and irreversibly inhibits MAO-B (which selectively metabolizes dopamine),
  • Retards breakdown of dopamine in the brain.
  • Enhances the effect of levodopa.
  • Allows dose of levodopa to be reduced.
  • Little potential for causing hypertensive crises.
  • Mainly used as adjunct to levodopa.
34
Q

Rasagiline

A
  • Second MAO-B inhibitor approved for treatment of PD.

* Modestly helpful when taken alone for early disease or in addition to levodopa/carbidopa in advanced disease.

35
Q

COMT inhibitors

A
  • Inhibition of COMT by tolcapone & entacapone leads to:
  • Decreased metabolism of levodopa
  • Decreased plasma levels of 3-O-methyldopa
  • Increased uptake of levodopa
  • Higher dopamine levels in the brain.

ADVERSE EFFECTS
• Fulminating hepatic necrosis is associated
with the use of tolcapone
• Entacapone is not hepatotoxic and is therefore preferred.

36
Q

Amantadine

A
  • Antiviral drug with antiparkinsonian actions.
  • Increases synthesis, release or re-uptake of dopamine from the surviving neurons.
  • Less efficacious than levodopa and tolerance develops more readily, but it has fewer side effects.

SE’s
• May cause restlesness, agitation, confusion, hallucinations.
• At high doses: acute toxic psychosis.
• Peripheral edema: not accompanied by signs of cardiac, hepatic or renal disease; responds to diuretics.
• Amantadine should be used with caution in patients with a history of seizures or heart failure.
• Livedo reticularis sometimes occurs in patients taking amantadine. Usually clears within a month of withdrawing the drug.

37
Q

Antimuscarinics in PD

A
  • Adjuvant therapy.
  • May improve tremor and rigidity but have little effect on bradykinesia.
  • Can produce mood changes, xerostomia, pupillary dilation, confusion, hallucinations, urinary retention and dry mouth.
  • Cannot be used in patients with glaucoma, prostatic hypertrophy or pyloric stenosis.
38
Q

GAD txt

A
  • Antidepressants are first-line (replaced BZOS); reduce the psychic symptoms of anxiety with a modest effect on autonomic or somatic symptoms.
  • Onset of antianxiety effect takes 2 - 4 weeks.
  • Venlafaxine and SSRIs are usually preferred over TCAs due to improved safety and tolerability.

BENZODIAZEPINES
• Recommended for acute treatment of GAD when short-term relief is needed, as an adjunct during initiation of antidepressant therapy, or to improve sleep.

BUSPIRONE
• Buspirone does not have abuse potential, does not cause withdrawal reactions, and does not potentiate alcohol and sedative-hypnotic effects.
• Has a gradual onset of action (i.e., 2 weeks).
• Does not provide immediate anxiety relief.
• Second-line agent for GAD due to inconsistent data regarding its efficacy.

ALTERNATIVE AGENTS - 3rd line
• Hydroxyzine and pregabalin.

39
Q

Panic disorder txt

A

ANTIDEPRESSANTS
• SSRIs are the drugs of choice.
• A TCA or MAOI may be effective when an SSRI is not.

BENZODIAZEPINES
• Not preferred for long-term treatment.
• May be used when patients fail several antidepressant trials.
• Alprazolam, although widely used, may cause rebound anxiety between doses and has been associated with a withdrawal syndrome, including seizures.

40
Q

SAD txt

A

SSRIs
• SSRIs are the drugs of choice due to their tolerability and efficacy.
• The onset of response may be as long as 8 to 12 weeks.

41
Q

OCD txt

A
  • Clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline are all FDA- approved for OCD.
  • Comparisons show no difference in efficacy between clomipramine and the SSRIs.
  • The SSRIs have a better adverse effect profile.
  • For highly anxious OCD patients, adding a benzodiazepine or an antipsychotic drug may be beneficial.
42
Q

PTSD txt

A
  • SSRIs are the first-line drugs.
  • Other antidepressants (e.g., venlafaxine, TCAs and MAOIs) can also be effective, but they have less favorable side-effect profiles.
  • Sertraline and paroxetine are both approved for the acute treatment of PTSD.
  • Sertraline is approved for the long-term management of PTSD.
43
Q

Performance anxiety txt

A

• Propranolol and other B-blockers are the preferred treatments.

44
Q

Antiepileptics that block Na+ channels

A
Principal mechanism of action of 
• Phenytoin
• Lamotrigine
• Carbamazepine 
• Zonisamide

It may contribute to the effects of
• Phenobarbital
• Valproate
• Topiramate

45
Q

Antiepileptics that block T-type Ca2+ channels

A
  • Absence seizures involve oscillatory neuronal activity between thalamus and cortex.
  • The T-type Ca2+ current governs oscillatory responses in thalamic neurons.
  • Ethosuximide and valproate inhibit this current and are effective in absence seizures.
46
Q

Drugs that enhance GABAergic transmission

A
Postsynaptically
Direct action on the GABA receptor -> increase Cl- influx
• Benzodiazepines 
• Barbiturates
• Topiramate

Presynaptically
• Inhibition of the reuptake of GABA: Tiagabine.
• Inhibition of degradation of GABA: Vigabatrin inhibits GABA aminotransferase.
• Increase of GABA release: Gabapentin & pregabalin.

47
Q

Drugs that reduce glutamatergic transmission

A

Postsynaptically -> decreased Na+ entry
• Phenobarbital & topiramate block glutamate receptors.

Presynaptically
• Gabapentin and pregabalin decrease glutamate release by blocking presynaptic voltage-gated Ca2+ channels.

48
Q

Simple and Complex Partial and Secondarily Generalized Tonic-Clonic Seizures

A
  • Drugs of choice are carbamazepine, oxcarbazepine, lamotrigine, or phenytoin.
  • Valproate and topiramate are also used.
  • New drugs (eg, gabapentin, pregabalin, zonisamide) can be used as adjuncts.
  • Phenobarbital is used for generalized tonic-clonic and complex or simple partial seizures.
  • It may also be used for myclonic seizures.
  • It used to be a first-line drug, but it is now second-line because of its adverse effects: sedation, depression and agitation.
49
Q

Generalized seizures

A

Tonic-Clonic Seizures
• Valproate, carbamazepine and phenytoin are
the drugs of choice.
• Lamotrigine and topiramate are also approved for this indication.

Absence Seizures
• Drugs of choice: ethosuximide and valproate.
• If tonic-clonic seizures are present valproate is the drug of choice.
• Valproate is also preferred for atypical absence seizures.
• Clonazepam is effective, but sedation is prominent and tolerance may develop.
• Acetazolamide may be effective but tolerance develops.

50
Q

Myoclonic seizures

A

• Valproate is the drug of choice.

51
Q

Atonic seizures

A
  • Atonic seizures are often refractory to all drugs.
  • Valproate and lamotrigine may be beneficial.
  • Benzodiazepines may improve seizure control in some patients but may worsen attacks in others.
  • Felbamate is effective in some patients, but the drug’s toxicity limits its use.
52
Q

Infantile spasms

A
  • Corticotropin or glucocorticoids are commonly used. Their mechanism of action is unknown.
  • Vigabatrin is also effective.
  • Other drugs that have been used include valproate, clonazepam, pyridoxine, felbamate and lamotrigine.
53
Q

Febrile convulsions

A
  • If seizures last < 15 minutes treatment is supportive.
  • Seizures lasting > 15minutes require pharmacological treatment to prevent brain damage.
  • Treatment: diazepam given IV or as a rectal solution.
54
Q

Status epilepticus

A

IV Lorazepam

Seizures continuing
IV Phenytoin or Fosphenytoin

Seizures continuing
IV Phenobarbital

Seizures continuing
General anesthesia with IV midazolam, propofol, or barbiturates

55
Q

Other seizures

A

• Drug-induced seizures in nonepileptic patients may be controlled with diazepam, lorazepam or phenobarbital.

  • Breakthrough seizures are seizures experienced by epileptic patients who are on antiepileptic therapy.
  • Diazepam rectal gel is approved for breakthrough seizures.
  • Supplied as a pre-filled syringe.
56
Q

Antiepileptic SE’s

A
Valproate
• Hepatotoxicity.
• Inhibits cytochrome P450.
• Inhibits metabolism of several drugs. 
• Inhibits its own metabolism.
Phenytoin
• Nystagmus, diplopia, ataxia.
• Gingival hyperplasia.
• Coarsening of facial features in children. 
• Hirsutism.
• Zero order kinetics of elimination.

Carbamazepine
• Aplastic anemia, agranulocytosis & thrombocytopenia (rare).
• Skin rash.

Vigabatrin
• Long-term therapy associated with irreversible visual field defects in 1/3 of patients.

57
Q

D/Cing antiepileptics and OD

A
  • If a patient is seizure-free for 3-5 years discontinuation is warranted.
  • Discontinuation should be slow.
  • Benzodiazepines and barbiturates should be discontinued very gradually to avoid withdrawal seizures.
  • If the patient is on combination therapy, drugs should be withdrawn one at a time.

• Antiepileptic drugs are commonly taken in intentional drug overdoses.
• Antiseizure drugs are rarely lethal.
• The most dangerous effect after large overdoses
is respiratory depression.
• Treatment is supportive.
• Stimulants should not be used.

58
Q

Teratogenicity

A
  • Valproate appears to cause a significantly higher rate of fetal malformations compared to other antiepileptic drugs.
  • Prophylactic use of folic acid is recommended for all women of childbearing age because it decreases incidence of neural tube defects.
  • Enzyme-inducing antiepileptic drugs may increase degradation of vitamin K in the fetus.
  • This can cause bleeding in the newborn infant.
  • Vitamin K supplementation is recommended for the mother in the final month of pregnancy and for the newborn.
59
Q

Other uses of antiseizure drugs

A
  • Carbamazepine: Neuropathic pain; bipolar disorder.
  • Gabapentin: Neuropathic pain.
  • Lamotrigine: Bipolar Disorder.
  • Pregabalin: Neuropathic pain.
  • Topiramate: Migraine.
  • Valproate: Bipolar disorder; migraine.