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Stroke & Sleep Flashcards

1
Q

mini stroke due to brief blockage of blood flow to the brain with temporary symptoms that go away quickly

A

transient ischemic attack

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2
Q

modifiable risk factors for stroke

A

hypertension, hyperlipidemia, smokinh, diabetes, Afib, CAD, obesity, post-menopausal hormonal therapy

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3
Q

nonmodifiable stroke risk factors

A

age >55, black/hispanic race, male FH, PH of stroke

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4
Q

most important piece of history for med administration for stroke

A

when was the last time they were normal

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5
Q

symptoms of stroke

A

visual changes, facial droop, motor function of arms/legs, limb ataxia, sensory changes, language, dysarthria

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6
Q

therapeutic time window for stroke for reversible deficits

A

<2 hours

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7
Q

therapeutic time window for stroke for some but incomplete recovery

A

2-6 hours

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8
Q

therapeutic time window for stroke for little recovery

A

> 6 hours

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9
Q

BP goals for someone who is not a candidate for thrombolytics

A

permissive HTN up to 220 mmHg systolic

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10
Q

2 choices of thrombolytics for stroke

A

alteplase (TPA)
tenecteplase (TNK)

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11
Q

AE of thrombolytics

A

intracerebral hemorrhage

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12
Q

BP goals while on thrombolytics

A

systolic <180 mmHg and diastolic <110 mmHg for 24 hours

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13
Q

IV agents for BP management for thromboloytics

A

labetalol and nicardipine

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14
Q

main reasons TNK differs from TPA

A

bolus only, longer half life

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15
Q

symptoms of a bleed from thrombolytics

A

acute neurologic change, HA, NV, acute HTN, lethargy

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16
Q

inclusion criteria for thrombolytics

A

ischemic stroke diagnosis
symptoms onset <4.5 hr prior to treatment
18 or older
deficit measured on NIHSS
CT w/ no evidence of ICH

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17
Q

when does 3 hours become the cutoff for thrombolytics

A

80 or older, severe stroke

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18
Q

2 main B&W exclusion criteria for thrombolytics

A

seizure at stroke onset
anticoagulants in the last 48 hours

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19
Q

drug class chosen for stroke prophylaxis when a small vessel lacunar, large vessel embolic, or large vessel thrombotic stroke

A

antiplatelet therapy

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20
Q

drug class chosen for stroke prophylaxis when cardioembolic

A

anticoagulant

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21
Q

MOA of clopidogrel & ticagrelor

A

irreversibly blocks ADP receptors on platelets

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22
Q

MOA of aspirin

A

inhibits COX1 and thromboxane

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23
Q

why is prasugrel not used for stroke

A

BBW/CI for stroke
increased risk for cerebral hemorrhage

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24
Q

plavix is a prodrug activated by _ & __ which can lead to DDIs

A

CYP3A4 & 2C19

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25
Q

potential 3A4 & 2C19 DDIs with plavix

A

statins (not crestor)
CCBs
Ambien/Lunesta
Glyburide
PPIs

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26
Q

max dose of ASA when taking brilinta

A

100 mg

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27
Q

potential DDI that can affect ASA

A

NSAIDs (not celecoxib)
herbals

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28
Q

antiplatelet agent not really used anymore than inhibits plasma adenosine and platelet phosphodiesterase

A

dipyridamole (Aggrenox)

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29
Q

do not use which antiplatelet with migraines

A

aggrenox

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30
Q

avoid this antiplatelet agent with spastic colon or irritable bowel

A

ASA

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31
Q

scenarios requiring DAPT for stroke

A

coronary artery stents
new cerebral ischemia
Afib not candidate for anticoag
cerebral vessel dissection
fail mono
high risk post stroke 1st 3-6 mos

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32
Q

drugs that can cause insomnia

A

alcohol, caffeine, nicotine, anticholinergics, SSRI, SNRI, a-block, b-block, ACE, ARB, cholinesterase inhibitors, bronchodilators, CNS stimulant, corticosteroids, decongestants, diuretics, H2RA2, statins, opioids

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33
Q

drug for sleep ONSET when want to avoid BZRA and morning sedation

A

ramelteon

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34
Q

drug choices for sleep ONSET when want to avoid BZRA and do not care about morning sedation

A

DORA or ramelteon

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35
Q

drugs for sleep ONSET when not avoiding BZRA and want to avoid morning sedation

A

non-benzo BZRA (zalep, zolp), ramelteon

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36
Q

drugs for sleep ONSET when not avoiding BZRA and do not care about morning sedation

A

DORA, non-benzo BZRA, ramelteon

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37
Q

which benzo has the most favorable safety profile for insomnia

A

temazepam

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38
Q

agents with what indication for insomnia may have a higher risk for morning sedation

A

dual indication for maintenance and onset

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39
Q

drugs of choice for insomnia in elderly

A

ramelteon, low dose doxepin&raquo_space; eszopiclone, zolpidem

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40
Q

drugs of choice for insomnia in pregnancy

A

diphenhydramine, doxylamine&raquo_space; low dose doxpein

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41
Q

drugs of choice for sleep MAINTENANCE when want to avoid BZRA

A

DORA or doxepin

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42
Q

drugs of choice for sleep MAINTENANCE when do not want to avoid BZRA

A

DORA, doxepin, non-benzo BZRA

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43
Q

MOA of BZDRAs

A

agonist at GABA receptors

44
Q

AEs of BZDRAs

A

drowsy, dizzy, confusion, falls, withdrawal when d/c

45
Q

caution for what AE and use in who for BZDRAs

A

complex sleep behaviors
caution in elderly

46
Q

counsel on avoiding what when taking BZDRAs

A

avoid alcohol and opioids

47
Q

benzo for insomnia with longest t1/2

48
Q

benzo for insomnia with quickest onset of action

A

flurazepam

49
Q

which 2 benzos for insomnia have metabolites

A

quazepam, flurazepam

50
Q

caution using benzos in pt with

A

sleep apnea or sub abuse

51
Q

BBW for benzos

A

concomitant opioid use, risk for abuse/dependence

52
Q

are benzos or z drugs more disruptive of sleep stages

53
Q

Z-drug BBW
do what if this occurs?

A

complex sleep behaviors, may result in injury (ex sleepwalking)
d/c therapy

54
Q

how should z drugs be taken

A

immediately before bed with 7-8 planned hours of sleep

55
Q

how is absorption of eszopiclone and zaleplon affected by food

56
Q

eszopiclone & zaleplon can have DDI with

A

3A4 inhibitors for eszopiclone
inducers for zaleplon

57
Q

which Z drug is ultra short acting with rapid onset used ONLY FOR SLEEP ONSET

58
Q

dosing of zolpidem differs for

A

males vs females

59
Q

formulations of zolpidem include

A

SL, ER, IR tab, IR cap

60
Q

orexin A and B receptor antagonists which turn off wake signaling

A

suvorexant
lemborexant
daridorexant

61
Q

DORAs are CI in

A

narcolepsy

62
Q

DORAs have a DDI with

63
Q

which DORA has the longest t 1/2

A

lemborexant

64
Q

AEs of suvorexant

A

sleep paralysis, abnormal dreams

65
Q

AEs of lemborexant

A

complex sleep behaviors, abnormal dreams, NEXT DAY DROWSINESS/FALL RISK
(prolonged CNS depression due to t 1/2)

66
Q

which DORA has delayed absorption with food

A

daridorexant

67
Q

AEs of daridorexant

A

complex sleep behaviors, hallucinations, sleep paralysis

68
Q

melatonin receptor agonist that induces sleepiness and regulates circadian rhythm

69
Q

ramelteon is indicated for what? why?
how long?

A

ONSET, quick onset and short t1/2 long term

70
Q

insomnia agent that blocks reuptake of serotonin and NE and antagonizes H1

71
Q

doxepin is used for what??

A

MAINTENANCE

72
Q

how long to avoid food before/after doxepin

A

do not take within 3 hours

73
Q

supplement OTC used for insomnia

74
Q

do not use melatonin in

A

autoimmune conditions
Alzheimer’s

75
Q

agent used off label to help sleep continuity

76
Q

which comorbidities may trazodone be good for

A

hx of sub abuse and/or depression

77
Q

AEs of trazodone

A

carryover sedation & alpha block –> orthostasis

78
Q

2 antihistamines used for insomnia

A

diphenhydramine, doxylamine

79
Q

what is the standard of treatment for obstruct sleep apnea

A

positive airway pressure (PAP)

80
Q

lifestyle mods for sleep apnea include

A

weight loss, change sleep position, avoid alcohol and sedatives

81
Q

which drugs to avoid in sleep apnea

A

CNS depressants
drugs causing weight gain

82
Q

which 4 drugs are used for excessive daytime sleepiness in sleep apnea

A

modafinil, armodafinil
solriamfetol
pitolisant

83
Q

modafinil & armoadifinil may have a DDI with

A

OCs effectiveness decrease

84
Q

main AE of modafinil/armodafinil

85
Q

caution using modafinil or armodafinil in patients with

A

CV disease

86
Q

warnings of modafinil and armodafinil include

A

mania, CV events, SJS/TEN, DRESS

87
Q

when should EDS drugs be taken

A

upon awakening

88
Q

EDS drug that blocks DA & NE reuptake

A

solriamfetol

89
Q

avoid solriamfetol in patients with

A

unstable CV disease, arrhythmias

90
Q

solriamfetol is CI with

A

use of an MAOI

91
Q

avoid administration of solriamfetol within

A

9 hours of sleep

92
Q

EDS drug that is an antagonist/inverse agonist at H3 receptors

A

pitolisant

93
Q

AE of pitolisant

94
Q

3 main symptoms of narcolepsy that can be treated

A

EDS
cataplexy
REM sleep abnormalities

95
Q

5 agents used for EDS ONLY in narcolepsy

A

modafinil, armodafinil, solriamfetol, amphetamines, methylphenidate

96
Q

4 agents used for CATAPLEXY ONLY in narcolepsy

A

venlafaxine, fluoxetine, duloxetine, clomipramine

97
Q

2 agents used for BOTH EDS AND CATAPLEXY in narcolepsy

A

sodium oxybate, pitolisant

98
Q

sodium oxybate is a

A

CNS depressant

99
Q

how is sodium oxybate administered

A

at bedtime on empty stomach (2 hours after food) lie down immediately after, stay there, 2nd dose in 2.5-4 hours

suspension is a single dose

100
Q

BBW for sodium oxybate

A

CNS depression, abuse/misuse, restricted access

101
Q

following admin of sodium oxybate do not…. (rems)

A

do not engage in hazardous activities requiring mental alertness or motor coordination for at least 6 hours after taking

102
Q

meds of choice if needed for jet lag

A

melatonin, ramelteon, Z drugs, BZDs

103
Q

drugs of choice for shift work disorder

A

melatonin, ramelteon, suvorexant, Z drugs, BZD, modafinil/armodafinil

104
Q

withdrawal of which meds can cause restless legs syndrome

A

central acting antihistamine
antidepressants
antipsychotics
anti-nausea that act on DA

105
Q

drugs for intermittent symptoms of RLS

A

carbidopa levodopa
BZDRA (clonazepam)

106
Q

alpha-2-delta Ca channel ligands used for chronic persistent RLS symptoms (especially painful)

A

pregabalin, gabapentin

107
Q

DA agonists used for chronic & persistent ALS symptoms

A

IR pramipexole, ropinirole, rotigotine

Therapeutics (34 decks)

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