seizures and parkinson Flashcards
1
Q
parkinson’s is the loss of dopamine continuing neurons in the _____ where they
A
substantia nigra inhibit the firing of cholinergic neurons
2
Q
three broad mechanisms of parkinsons drugs
A
dopamine replacement
dopamine agonist therapy
anticholinergic
all of which aim to correct the imbalance of the cholinergic neurons in the striatum
3
Q
this drug is a metabolic precursor of dopamine that crosses the bbb
A
levodopa
4
Q
why are large doses of levodopa necessary in tx
what is the problem with this
A
because the drug is decarboxylated to dopamine in the periphery
this causes side effects
5
Q
carbidopa
A
dopamine decarboxylated inhibitor that does not cross the BBB
this reduced the peripheral metabolism of levodopa and increases the amount that reaches the brain
6
Q
Selegiline/deprenyl MOA
A
inhibitor of monoamine oxidase
this is the enzyme that metabolizes dopamin in the CNS
7
Q
Rasagiline
A
newer monoamine oxidase inhibitor similar to selegiline
8
Q
this drug is known for disabiling response fluctuations over time
A
levadopa
9
Q
mnemonics for parkinson’s tremor
A
MAIN- bradykinesia (slowness)
TRAP-motor
tremor at rest
rigidity
akinesia
postural stability
SOAP-non motor
sleep disturbances
other: nausea fatigue, speech
autonomic
psychologic
10
Q
two classes of medications that cause parkinsonism
A
anti-psychotics
anti-nausea
both result in the loss of dopamine
11
Q
7 categories of anti parkinsons drugs
A
Anticholinergic Amantadine COMT Dopamine Dopamine agonists MAO-B inhibitors
12
Q
name the two anithcholinergic drugs used for parkinsons
A
benztropine
trihexyphenidryl
13
Q
COMT inhibitors
A
entacapone
tolcapone
14
Q
dopamine agonsits
A
apomorphine
bromocriptine
praipexole
ropinirole
15
Q
MAO inhibitors
A
rasagiline
selegiline
16
Q
what are the PK issues with levadopa
A
do not take with high protein meal because its absorption is affected by the diet
17
Q
LAAD inhibitor
A
L-amino acid decarboxylase inhibitor
carbidopa
18
Q
CI or carvidopa levodopa
A
narrow angle glaucoma
non-selective MAOIs- hypertensive cris
19
Q
drug resistant off periods with levodopa carbidopa are due to
A
delayed gastric emptying or decreased GI absorption
GIVE ON EMPTY STOMACH
try to avoid control released products
20
Q
what drugs would you not want to give with a pt on levodopa
A
dopamine antagonists: antipsychotics and antiemetic
non-selective MAOI
buproprion:increased side effects
protease inhibitors:toxcitiy
phenytoin, ion: reduce the IO-dope efficacy
21
Q
AE to levodopa
A
GI effects common: nausea vomiting
postural hypotension and unstable balance
arrhythmias (low incidence)
sedation/vidi dreams/
22
Q
why do we see the end of dose effect with levodopa
what can you do to help prevent this
A
increasing loss of neuronal dopamine storage
relying on exogenous source (med)
can increase dosing frequency
change to long acting
add short acting regimen to long acting
add other durgs
23
Q
COMT
A
methylates levadopa
24
Q
entacapone and
tolcapone both target what pathway
A
COMT methylation of L dopa
25
how doe tolcapone differ from decarboxylase inhibitors
blocks COMT in the brain and helps to increase the levlels of dopamine and
26
tolcapone SE
cna increase liver enzymes causing failure
27
how does MOA B differ from antidepressants
selective targets dopamine degradation therefore MOABI like selegiline and rasaligine slectively target this and prevent degradation in the CNS
these durgs only have minor effects when given alone and are used mostly in conjungtion with levadopa
28
MOA of ropinarole
D2 receptor agonist similar to bromocriptine
paramipexole (D3)
29
viral agetn that increase dopamine release and uptake and can be used for parkinson's
amantadine
30
benztropine
trihexyphenidryl
how do thye work
benztropine
trihexyphenidryl
antimuscarninic agent
help restore balance of dopamernergic and cholinergic activity
centrally acting antimuscarinic that effect tremor but not effect of brady
help with parkinsonism effects of drugs
used if tremor is a big side effect
31
vomiting before abdominal pain think
medical
32
pain before vomiting think
surgical
but be prepared for either or both
33
if you see hmg drop by
more than a point in a week you check occult blood three time
sometimes the bleeding is proxismal
34
SIRS
criteria that they
defined as at least 2
heart rate >90
RR >20 <32
temperatrue <96.8 (36) or >38 > 100.4
WBC>12 or <4 or with >10% bands
35
SE with parmipexole ropinorle and bromocriptine
common nausea confusion hallucinations light headedness LE edema
postural hypotension
sedation
serious: compulsive behavior physchosis, sleep attacks, pleuropulmonary fibrosis
36
what is a side effect that is exclusive to ergot derivatives
pleuropulmonary fibrosis
37
drug interactions with bromocriptine
w/ bromocriptine
azole
antifungals
protease inhibitors
erythromyocin
increase bromocriptine
38
DI with ropinirole
altered metbaolism with CYP1A2 inducers and inhibitors
39
this drugs provides rapid effective temporary relief of off period akinesia
apomorphine
40
apomorphine
effective temporary relief of off period akinesia
SI
N/V
premedicate with trimethobenzamide
41
trimethobenzamide
used for N/V associated with apomorphone (off period akinesia)
can cause dizziness hallucinations an ink site irritation
42
trimethobenzamide CI
5HT3 receptor blockers
43
rotigotine
row to go tin
dopamine agonist patch also used in RLS
44
what is special about apomorphine
the first dose of apomorphine must be given in a clinic setting. The patient should not take apomorphine if he is allergic to metabisulfite.
The dose should be re-titrated if he has not taken apomorphine for 1 week.
Apomorphine causes severe nausea and vomiting.
45
two COMT inhibitors and the differences between their side effects
entacapone: peripheral SE
tolcapone: central and peripheral
46
of the two COMT I which one can cause hepatotoxcity
tolcapone:
47
COMT
degrades dopamine in periphery AND CNS
48
if the pt is taking levodopa and about to start a COMT what should be done first
reduced levodopa by 30% in first 48 hours to avoid ADE
49
other than hepatotoxicty with tolcapone what SE would we expect to see with COMT I
orange brown urine delayed onset diarrhea
50
COMT I interact with
NONSELECTIVE :
| MOAIs
51
the uses of COMTI
reduced off time and increase l-dopa AUC by 35%
allow for reductions in L-dopa
52
1st line for managing motor fluctuations with pts on L dopa
entacapone
53
when would we used tolcapone
reserved for pts with fluctuations that are not responding to other therapies
54
MAOB inhibitors work selectively in the
CNS
increases dopamine in the brain
55
MAOBI
rasagiline
safinamide
selegiline
safari
and giline MOUSE
56
when would we use MAOBI transdermal patch
depression only
57
Adverse effects of selegiline
SILLY rat
the same as everything else
+ DIZZINESS HA
rare: atrial fibb
58
Adverse effects of rasagiline
red rat
same as every other parkinsonian drug
+vomiting
depression
dyskinesia
orthostatic hypotension
rare: GI hemorrhage
59
Adverse effects of safinaminde
safari rat
same as other PD drugs except for fall
rare: hypertension and hallucinations
60
what kind of drugs are CI with MAOB
```
other MAOIS
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (Emsam)
Tranylcypromine (Parnate)
```
```
and opiods and OTC cold
meperidine
methadone
tramadol
porpoxyphene
dextromethrophan
```
61
what should you advise a pt ot MAOI
avoid all OTC cold prep
don't take with other MAOIS
Serotonin syndrome :use in caution with pts on antidepressants
avoid NON SELECTIVE MAO inhibitors -hypertensive crisis life trhreatening
(accumulation of NE )
62
which MOA B I can be used as monotherapy
rasagiline
63
this is thought to be the MOA of amantainde
may potentiate dopaminergic function
NDMA antagonis--> anti-dyskinetic
64
why don't we use amantadine regualrly
short lived
| less effective than l-dopa
65
amantadineSE
most of the mental
```
depression
irritability
excitability
agitation
confusion
```
66
livedo reticularis
reversible duffuse skin mottling and often LE edema
seen with amantadine
67
these types of medications are used for symptomatic control of tremors only
anticholinergics
bextropine (cogentin)
trihexyphenidyl (artane)
trihex benz car aretan
68
what population do you want to be weary of with anticholinergics
geriatric lower doses and titrate slowely
worried about confusion
constipation
dry mouth
urinary retention
69
what is your first approach to the pt with IPD
non pharmacologic: education, exercise, nutrition, psychosocial
or consider rasagiline
70
what do you do for a pt on rasagiline who needs additional tremor control
if under 65 anticholinergic or amantadine
if over 65 amantadine
71
what do you do for a pt on rasagiline who continues to experience symptoms of bradykinesia rigidity or tremor
add amantadine
DA agonist
or Carbidopa L-dopa
72
delayed onset fluctuations seen as bradykinesia at the beginning of dosing intervals is known as
delayed onset
73
what is peak-dose dyskinesia
involuntary movement at peak levodopa levels
74
how do you treat response fluctuations
keep extra dose with you in case meds wear off while out
longer acting meds
maximize on time
minimize off time
75
what can you do for a pt that experiences wearing off
ass MAO BI
ADD COMT I
ADD DOPAMINE AGNOSIT
ADj dosing
76
what to do for on-off phenomenon
add entacapone rasagiline pramipexole ropinirole or selegiline
redistribute dietary preotein and space meds 2 hours from a meal
77
focal seizures are defined as
what are the three categories
arising from localized regions of the brain and can be
simple (focal aware)
complex (focal impaired awareness)
secondary generalized (focal to bilateral)
78
generalized seizures definition and categories
involve both hemispheres LOC and may be convulsive or non-convulsive
absence (petit mal)
tonic-clonic (grand mal) : both phases
myoclonic
atonic (loss of muscle tone)
79
ion channel phsyiology in seixures
selective pores for Na, K, Cl, Ca
ATP dependent Na/K pump that maintains resting membrane potential at -70 mV
concentration gradient: K inside Na outside
when opened Na movies in and K moves out
charges change confirmational state of voltage gated chanels and Na and Ca depolarize the membrane
80
four broad classifications for the MOA of anti seizure drugs
(1) modulation of voltage-gated sodium, calcium, or potassium channels
2) enhancement of fast GABA-mediated synaptic inhibition
(inhibitory GABA)
(3) modification of synaptic release processes
(4) diminution of fast glutamate-mediated excitation.
81
when would you start therapy for individuals experiencing seizures
first seizure for high risk pts
| all pts at seocnd seizure
82
when pt is still experiencing seizures despite medication regimen
if not decreasing in frequency
switch to second med with taper
if decreasing in frequency
maximize dose
add second agent
could potentially taper first
83
seizure medication options for pregnant women
oxclamotrigine, levetiracetam, zonisamide
84
seizure medication options for elderly with focal epilepsy
levetiracetam, lomotrigine
85
primary generalized med options
ethosuximide (absence only)
levetiracetam, lomotrigine, topiramate, valproate, zonisamide
86
partial onset (focal) with or w/ot secondary generalized properties meds
topiramate, levetiracetam, lomotrigine, oxclamotrigine, zonisamide
carbamazepine
oxacarbazepine
lacosamide
87
drugs to avoid in primary generalized
gabapentin
pregabalin
tiagabine
vigabatrin
88
what would you never want to use in a woman of childbearing potential
```
valproate (d)
Phenytoin
Carbamezapine
Oxcarbazepine
Phenobarbital
```
ALL category D
89
CBZ
carbamazepine
```
carbatrol
epitol
equetro
tegretol
tegretol-XR
```
90
PB
phenobarbital
91
PHT
phenytoin
dilantin
phenytek
92
VPA
VPA -valproate
```
depacon
depakaene
depakote
SPRINKLES
Stavzor
```
93
ESM
zarontin
| ethosuximide
94
PB MOA
enhances GABA evoked Cl- currents
barber taking up GABA
95
PHT MOA
blocks Na channels
towing car and carba both throwing out salty chips
96
CBZ
blocks Na channels
97
VPA
Valerie wearing her sprinkle coat is not about to eat salty chips either
or tea flavored ice cream
VPA blocks Na channels and T type Ca channels
98
ethosuximide/ESM MOA
aaron trying to be zaro still sux
he isn't eating tea ice cream either and he is skinny af
99
major drug old epi drug approved for JME
PB
100
which drug can be used off label for post-taumatic seizures following TBI
PHT
101
what is the main older epi med that can be used for status epi
PHT
phenytoin
my care is dying tow me call and check the STATUS of the tow truck
102
usual dosage of PB
Dzz-Mzz (100-300)
103
normal dosage and initial dosage of CBZ
Dzz-Nzz (100-200 BID)
800-1200 max
Fuzz- thinzz
104
see d think
2
105
see m think
3
106
8
F V
107
1
t or d
108
ESM dosage
Ethosuxamide
Start LESS of Aaron like half (250-500)
At the max you have to Tells him
TELSS 1500
109
VPA dosage
dL
15mg
max
shes
mx: 60
110
PB dose adj
hepatic and renal
barbershop with the kidney and the liver
111
PHT adjustments needed
need to monitor free unbound levels for liver
112
CBZ need what adjustment
use caution in liver
CrCL<10
dz
113
VPA adjustments
hepatic adjustment for moderate to severe
NO RENAL
val likes to drink but her kidneys are fine
114
ESM dosage adjustments
use caution in liver and kidney
115
which anti seizure meds are CYP inducers
PB
PHT
CBZ
116
cbz cns DEPRESSION se
Diplopia and drowsiness
117
dose related SE CBZ
HA
| N/V
118
idiopathic SE CBZ
Rashes
hyponatremia
bloody dyscrasias
119
VPA CNS SE
somnolence
120
VPA Dose-related SE
weight gain
N/V
alopecia
throbocytopenia
Val is gaining wait and bald playing the trombone
121
ESM CNS SE
drowsiness
aaron is tired
122
ESM dose related SE
anorexia
weight loss
abd cramps
123
ESM Idiopathic SE
```
leukopenia
eosinophilia
psychiatric
sleep disturbances
aggression
```
124
VPA idiopathic SE
drug rashes
hepatotox
pancreatitis
thrombocytopenia
drinking
playing the trombone epigastric pain
rash
125
what are some common ASE shared between
PB PRM PHT CBZ VPA and ETH
drowsiness
GI
hepatic dose
all renal dose except: VPA and PB
126
VPA most significant adverse SE
thrombocytopenia
127
ESM most significant SE
aggression
128
when to draw blood for PHT
whats the range
about every 2 weeks
MS (30) you're getting towed
you want to be between TOSS and NICE
129
CBZ therapeutic range
R - tin
greater than
TL you're done
130
VPA range
L- TNL
5-125
Over TNS 150 not good
131
CBZ blood draw
4-6
RaaSH
132
LTG
lamotrigine
lamictal
133
GBP
gabapentin
| neurontin
134
TPM
Topiramate
| topamax
135
LEV
levetiracetam
| keppra
136
OXC
oxcarbazepine
| trileptal
137
PGM
pregablin lyrica
138
ZNS
zonisamide
| conegram
139
LTG MOA
blocks Na channles
140
GBP MOA
Unknown but probably increases gaba synth
141
TPM
blocks Na channels
142
PGB MOA
modulates the influx of Ca by binding to presynaptic voltage gated channels
gabling lyrica is fucking with the wires on the ice cream truck
143
OXC MOA
blocks Na channels
144
ZNS MOA
blocks Na and T-type Ca
similar to VPA
145
Lacosamide MOA
vimpat
binds to collapsing response mediated protein 2 to enhance inactivation of Na
Waco pat isn't letting the potato chip truck arrive
146
LTG is indicated for
partial
GTC
LGS
off label absence
147
when would you use GBP
ADJ for partial
148
rare and severe kind of epilepsy that starts in childhood
LGS
149
what two drugs can you use for LGS
GBP
| LTG
150
what new epi meds can be used as an adjunct for children under the age of two
OXC
151
PGM and ZNS are both used as
partial adjunct
152
what new epi drugs would you see dose related weight gain with
GBP
| PGB
153
what new epi drugs would you see dose related weight loss
ZNS
| TPM
154
N/V are common with every single new epi drug except
GBP '
only SE are somnolence and weight gain
155
acute angle glaucoma is a idiopathic SE of what antiepi med
TPM
156
TPM idiopathic SE
glaucoma
acute-angle glaucoma
oligohydrosis
hyperthermia
157
systemic life threatening rash and hepatic failure are idiopathic SE of this antiepi drug
LTG
158
what anti epi drugs would you see associated with blood dyscrasias
CBZ and OXC
159
peripheral edema and thrombocytopenia are associated with this new antiepi
PGB
160
this new anti epi is associated with sulf allergies
ZNS
161
all newer antiepi casue drowsiness except
lacosamide
162
all new epi cause GI effects except
GBP and PGB
163
all new anti epi drugs require hepatic dose adj except for
GBP
PGB
LEV
ALL REQUIRE RENAL
164
slowing psychomotor disturbances and significant CI are all associated with what newer ant epi
TPM
165
mood changes are associated with what newer epi
LEV/ keepra
166
status epilepticus
any seizure lasting longer than 30 minutes with or without LOC
recurrent seizures with no intervening period of consciousness
may be convulsive or non-convulsive
167
tx of status
oxygenation preservation of cardioresperatory function
Benzos: IV push of lorazepam or diazepam
or
PHT/fosphenytoin IV loading dosed followed by PO maintenance
alt: PB
168
Monitoring needed for PB
CBC w/ diff and LFTs anually
serum Ca and bone scan periodically
169
PHT monitoring
ALBUMIN huge deal and LFT anually
CBC with differential every 6 -12 mo
Ca and vitamins levels as well as DEXA scan
170
monitoring with CBZ and VPA
CBC with differential and platelets q3mo and then every 6 mo
LFTs
for CBZ also need CMP every 6 mo
171
when should you consdier stopping therapy
no seizure >2 years
IQ, neurological test
no previous unsuccessful attempts at drug discontinuation
normal neurologic examination
consider risk vs benefits
normal EEG
single type of partial or generalized with mixed there is a heightened ris
172
what is the major teratogenic drug we worry about anti-epileptics
valproate
```
as well as
CBZ
PB
PHT
TPM
```
LMT
173
these drugs have known transfers to breast milk
```
LMT
primidone
LVT
GBP
TPM
```
174
common AE with clonazepam
disinhibition
ataxia
severe
respiratory depression
physical dependence
175
these two antiepis have decreased clearance in geri population
CBZ
| LMT
176
decreased protein binding seen with these two anti epi in geri populations
PHT
| VPA
177
increased half life in geriatrics with this antiepi med
Diazepam
178
fewer AED in geriatic pop with this drug
LMT
low dose TPM
GBP
and LCT
179
poly
oligo
normal
AFI
8-18 = normal
, AFI ≤5 cm = oligohydramnios,
AFI ≥24 = POLY
180
causes of oligp
Urethral obstruction (e.g., posterior urethral valves)
Bilateral renal agenesis
Autosomal recessive polycystic kidney disease (ARPKD)
Chromosomal aberrations (e.g., trisomy 18)
Intrauterine infections (e.g., congenital TORCH infections)
In multiple pregnancies: twin-to-twin transfusion syndrome
```
Late or post-term pregnancies (> 42 weeks of gestation)
Placental insufficiency
Preeclampsia
Premature rupture of membranes
Idiopathic
```
181
PCN allergy GBS treatment
cephazolin
super severe PNC ampicillin allergy
clinda
vanco
182
Tx for mom with hep b
C section to avoid maternal mixing of blood
need to give baby hep B ivig and hep B vaccine (first day of life)
ideally you vaccinate mom prior to pregnancy
183
HIV
baby cares about viral load increase in viral loas means increase in infectious risk
CD4 count--> risk of opportunistic infection (think TORCH)
DOES NOT CROSS PLACENTA
184
Is mom immune to hep B or infected
Antigen wins --> infexted
INFECTED
e--> INFECTIOUS
ab--> immune
surface ab---> immune through vaccination of exposure
185
diagnoses in HIV
ELISA
viral blot
if she shows up with no testing
2+1
2 NTRI+1 NNRTI
1PI
186
NNRTI
nevirapine (c)
187
protease inhibitor
atazanavir (b)
188
When can you delivery vaginally with HIV
delivery VL<1000 and on HARRT
189
don't know mom's HIV status
AZT
AZT (zidovudine),
190
charcot's triad sx
Most patients have fever, jaundice, and right upper quadrant pain (Charcot triad).
