Week 12 Drugs that affect the CNS & ANS Flashcards
Topiramate (Topamax) is being prescribed to a school-aged child for partial seizures. As the summer approaches and temperatures rise, the nurse practitioner needs to include which of these in patient education?
Stay hydrated and avoid extreme high temperatures due to risk of decreased sweating and high fever.
Topiramate can cause oligohidrosis and hyperthermia.
A 23-year-old patient who suffered from tonic-clonic seizures was recently discharged from an acute care hospital. The patient needs continued education regarding the daily administration of phenytoin (Dilantin). Which statement by the APN demonstrates the important education needed when phenytoin (Dilantin) is administered?
Recommended teaching is to avoid alcohol
Phenytoin (Dilantin)
Drug Class Indication MOA #3 ADR #6 (Neuro, Cardiac, GU) Caution #3 Contraindication preg/lact peds clinical #2
Hydantoin
Indication: Tonic-clonic & partial complex seizures
MOA:
- Stabilize/Inhibit electrical discharges by affecting influx of Na+ ions
- Highly protein bound
- CYP450/liver metabolism
ADR:
- Neuro: agitation, ataxia
- Cardiac: Hypotension/Tachycardia
- GU (urine retention/discolor)
- SI
- Blood dyscrasias
Caution:
- Elderly (d/t highly protein-bound & sensitive to renal/hepatic impairment)
- hypotension
- HF
Contraindications:
-Sinus bradycardia, 2nd 3rd AV block,
Pregnancy/Lact: NO!
Pediatrics: OK
Clinical Considerations:
- Narrow Therapeutic range
- Sudden withdrawal = rebound seizures
Carbamazepine (Tegretol)
Indication MOA ADR #6 Caution Black Box Warning #4 preg/lact Monitoring #2 Patient education
Carbamazepine
Indication:
-Focal & Generalized onset seizures; Bipolar disorder
MOA:
-CYP450 inducer
ADR:
- Drowsy
- Tremor
- Behavior change
- SI
- multiorgan reaction
- Hepatoxicity
Caution:
-Elderly (increased confusion)
BLACK BOX WARNING:
- Development of Steven-Johnson syndrome
- Toxic epidermal necrolysis in Chinese (Skin peeling/blister)
- Blood Dyscrasia (depress bone marrow)
- Dermatologic toxicity
PREG/LACT: NO
Monitoring:
- CBC, CMP, TSH
- Narrow therapeutic Range
impairs thyroid function
Patient Education:
- Report new-onset skin lesions, bruising, fever, or sore throat
- Do not take with grapefruit juice
Lamotrigine (Lamictal)
Indication MOA ADR #5 Black box Clinical consideration Patient Education Drug Interaction Preg/lac peds @ increase risk for?
Adjunctive Tx w/ valproate & phenytoin*
Indication:
Partial seizures
Primary generalized tonic-clinic seizures
MOA:
-Inhibit presynaptic release of glutamate & aspartate
ADR:
- GI (N/V, constipation)
- Cardiac (CP, peripheral edema)
- CNS: (Sedation, diplopia, ataxia)
- SI (rare)
- Blood dyscrasia (rare)
- Multiorgan sensitivity reaction (rare)
BLACK BOX WARNING:
-Serious skin reactions (SJS)
Clinical Considerations:
- rebound status epilepticus w/sudden withdrawal
- Levels decreased by estrogens
Patient Education:
- Report New onset rash
- Avoid alcohol & OTC drugs
- hydration
Drug Interaction:
-Oral contraceptives (decrease levels of lamo)
PREGNANCY/LACTATION: NO
PEDS: >2years (increased risk of skin reaction)
Zonisamide
Indication MOA ADR #3 Contraindication Clinical Consideration Preg/lact Peds
Indication:
Partial seizures in adults
MOA:
-Blocks voltage dependent Na+ & Cl- channels
ADR:
- Somnolence
- blood dyscrasia (rare)
- Decreases sweating ==risk hyperthermia ***
Contraindication:
-Sulfa allergy
Clinical Consideration:
Rebound Seizures with sudden withdrawal
PREG/LACT: NO
Peds >16 years
ethosuzimide (Zarontin); phensuximide (Celontin)
drug class Indication MOA ADR #5 (3 rare) Patient Education #2 Clinical Consideration #2 Drug Interaction Preg lact peds
Succinimides
Indication:
-Absence seizures**
MOA:
- Delays Ca++ influx into neurons
- Decrease nerve impulses & transmission in motor cortex
ADR:
- GI (most common)
- CNS: Sedation
- Mood changes
- SI (rare)
- Blood dyscrasia (rare)
- systemic lupus erythematosus symptoms (rare)
Patient Education:
- Take w/food (GI upset)
- Do not take with alcohol
Clinical Consideration:
Narrow therapeutic index
Rebound seizures w/withdrawal
Drug interaction:
Birth control effectiveness decreased (back up needed)
Pregnancy: OK
Lactation: NO
Peds: >3years
Valproic Acid
Indication MOA #3 ADR #6 Caution Black Box Warning #2 Clinical Consideration #2 preg/lact Peds
Indication: Focal, gen., focal onset impaired awareness, absence seizures
MOA:
- ^GABA bioavailability
- mimic GABA action at postsynaptic sites
- Blocks Voltage Na+ channels
ADR:
- H/A
- Drowsy
- Weight gain
- Behavior changes
- SI (rare)
- Brain Atrophy (rare)
Caution:
-Elderly (Somnolence/Beers list)
Black Box Warning:
- Hepatoxicity
- Severe Pancreatitis
Clinical Consideration:
- Narrow therapeutic index
- Rebound seizures w/withdrawal
Pregnancy/Lact: NO
Peds >2years
Gabapentin
Indication MOA ADR #4 Caution #3 Peds Clinical Consideration #2
Indication: Focal Seizure
MOA:
-GABA analogue that binds
ADR:
- Drowsy/fatigue
- Peripheral Edema
- Neuropsych events
- SI (rare)
Caution:
- Renal impairment (excreted in urine)
- Elderly (lethargy Beers list)
- Substance abuse history
Peds >3 years (high-risk Neuro events)
Clinical Consideration:
- Absorption increased if taken with food
- Rebound seizures
Topiramate (Topamax)
Indication MOA #2 ADR #4 Caution Preg peds Clinical Consideration
Indication: Focal Seizure, tonic clonic seizure, migraines
MOA:
- Block Na+ channel
- potentiate GABA
- Not extensively metabolized, only minor phase one metabolism and high amount of unchanged drug in urine**????
ADR:
- Lethargy
- Mood changes (lethargy, depression)
- SI (rare)
- Decreased sweating/hyperthermia (rare)
Caution:
-Elderly (lethargy)
Preg: NO
Peds >3months
Clinical Considerations:
-Rebound seizures
Levetiracetam (Keppra)
Indication MOA ADR #5 Fun fact Caution preg peds Clinical Consideration
Indication: Focal and gen. onset seizure
MOA:
-Inhibit burst firing w/o affecting normal neuronal excitability
ADR:
- Somnolence*
- Mood change/Nervousness
- SI (rare)
- Derm reaction (rare)
- Blood dyscrasias (rare)
***Fewer drug-drug interactions
Caution:
-Elderly (somnolence)
Pregnancy: OK
Peds >1month
Clinical Consideration:
-Rebound seizures w/ withdrawal
What does the toxicity of Valproic Acid look like?
CNS depression, Confusion, Jaundice
**BBW hepatoxicity
What does the toxicity of Succinimides look like?
CNS depression, respiratory depression, N/V
**High risk sedation
Toxic symptoms of Carbamazepine (Tegretol)?
Hypertension, Tachycardia, Stupor, Agitation, Respiratory depression, nystagmus, urinary retention, seizures, coma
Anticholinergic Effects
Which anticonvulsant is least sedating?
Phenytoin
A 45-year-old patient is suffering from back pain due to severe muscle spasms. A centrally-acting muscle relaxant, tizanidine (Zanaflex), is prescribed. By which mechanism of action does tizanidine act?
Tizanidine (Zanaflex) binds to central alpha2 adrenergic receptors, which increases the presynaptic motor neuron inhibition and reducing spasticity.
Baclofen
Indication MOA ADR #3 Caution #3 pregnancy
Indication: Muscle Relaxant
MOA: Inhibits transmission mono&polysynaptic reflexes at spinal cord
ADR:
- Drowsy/Confusion/Sedation
- seizures
- Hypotension
Caution:
- Renal
- Elderly (Beer’s list sedating)
- seizure disorder
Pregnancy: NO
Cyclobenzaprine (Flexeril)
Indication MOA #2 ADR #3 Contraindication #4 Caution #2 Peds Clinical Considerations #2
Indication: Muscle Relaxant
MOA:
- mono&polysynaptic spinal cord reflexes;
- inhibits reflex arc to block messages that are maintaining spasm
ADR:
- *Anticholinergic effects
- hallucinations
- sedation
Contraindication:
- Hyperthyroidism
- HF
- Heart block/conduction disturbance
- Acute MI
Caution:
- Glaucoma
- Urinary retention
Peds >12years
Clinical Consideration:
- Risk of Serotonin syndrome
- Should not be used longer than 3 weeks
Tizanidine
Indication MOA ADR #4 Drug Interaction Clinical Considerations #2
Indication: Muscle Relaxant
MOA:
-Alpha2-adrenergic agonists inhibits presynaptic motor neurons
ADR:
- *anticholinergic effects
- Bradycardia
- Hepatoxicity (rare)
- Angioedema (rare)
Drug Interactions:
-CYP450
Clinical Considerations:
- Less sedating than Baclofen and Flexeril
- Do not stop abruptly = rebound tachycardia
What are the signs of serotonin syndrome?
Overactive reflexes & muscle spasms, high temperature, sweat, shivering, mental changes
What is the goal for choinersterase inhibitors to treat Alzheimer’s?
Goal is to prevent degradation of acetylcholine by acetylcholinesterase because it results in enhanced activity of acetylcholine.
Donepezil (Aricept); Rivastigmine (Exelon)
MOA
ADR #3
Drug Interaction #2
Caution #2
Donepezil (Aricept); Rivastigmine (Exelon) MOA: -Indirect cholinergic agonist -inhibits acetylcholinesterase to prevent break down of acetylcholine ADR: -Dizzy -Agitation -Tremor Donepezil drug interaction: -CYP450 -Anticholinergic drugs Caution: -Seizures -QT prolongation
Memantine (Namenda)
MOA
ADR
Caution
Clinical Considerations #2
MOA:
- NMDA Receptor Antagonist
- *Persistent stimulation of NMDA receptors by glutamate contributes to AD**
ADR:
-Confusion/dizzy/somnolence
Caution:
- Cardiovascular disease
- Renal
Clinical Consideration:
- Used in combination with Donepezil or Rivastigmine
- Best for neuropsych symptoms (agitation/behavior disturbances)
What are the signs of Donepezil & Rivastigmine toxicity?
Constricted pupils, excessive salivation, diarrhea
Which adverse drug reaction to a selective alpha1 antagonist would be the best reason to change to a different class of medication?
IMPOTENCE
The leading cause of nonadherence to a treatment regimen with alpha1-adrenergic antagonists is inhibition of ejaculation and impotence. These reactions should be reported to the health-care provider, who may choose a different drug to treat the disorder or change the dosage.
Each selective alpha1 antagonist carries a risk for significant first-dose orthostatic hypotension that may result in syncope, and tends to occur within 30 to 90 minutes of drug administration. How can this adverse reaction be minimized?
Giving the first dose at bedtime
Which alpha-1 selective antagonist would be best for an elderly person with BPH?
Tamsulosin
Which alpha-1 selective antagonist does not cause orthostatic hypotension?
Tamsulosin
Clonidine (Catapres)
Drug Class Indication MOA #2 ADR #5 Caution #3 Contraindication #2 Patient Education
Drug Class: Alpha-2 Agonist (Central)
Indication: HTN, ADHD
MOA:
HTN: stimulate Alpha2 in brainstem to activate inhibition = Reduced Sympathetic response from CNS “downregulates
ADHD: regulates prefrontal activity
ADR:
- Drowsy/Dry mouth
- Bradycardia
- Nightmares
- Impotence
- Constipation
Caution:
- Elderly (bradycardia/orthostatic hypotension)
- Coronary Insufficiency
- CVD
Contraindication:
- History Bradycardia
- Beta blockers (bradycardia)
Patient Education:
-Do not stop abruptly dd/t downregulation»_space;> rapid increase in BP
Methyldopa
Drug Class Indication MOA ADR #6 Caution #2 Contraindication #2 Clinical Consideration #2 Preg/lact Peds
Drug Class: Alpha-2 Agonist
Indication: HTN
MOA: Stimulate central alpha-2 receptors via metabolite alpha-methylnorepinephrine
ADR:
- Edema
- Sedation
- Bradycardia/Hypotension
- elevated LFTs
- blood dyscrasias (rare)
- Hepatoxicity (rare)
Caution:
- Severe coronary insufficiency
- Cerebrovascular disease
Contraindication:
- history bradycardia
- Active renal/liver disease
Clinical Consideration:
- Tolerance may need to add diuretic
- Avoid with Beta blockers (bradycardia)
Pregnancy/Lact: no
Peds: NO
Beta blockers (BBs) are generally contraindicated in which patient?
unstable bronchospastic disorders such as asthma.
Beta blockers play a key role in the reduction of catecholamine response that stimulates the sympathetic nervous system (SNS). How do these medications perform their action?
Beta blockers occupy the receptor, impeding the ability for the neurotransmitter to stimulate the SNS.
Metoprolol; Atenolol
Drug Class Indication #4 MOA ADR #5 Caution #3 Contraindication #3 Peds Clinical Consideration #2
Drug Class: Selective Beta blocker
Indication: HF HTN Afib Angina, post MI
MOA:
-Block beta-1
ADR:
- Hypertension
- Bradycardia
- Dizzy, fatigue*
- depression
- Impotence/decreased libido
Caution:
- PVD
- DM (Masks symptoms of hypoglycemia except for sweating)
- Hyperlipidemia (decreases HDL, Increases cholesterol)
Contraindication:
- History bronchospasm
- Heart Block
- Pregnancy 1st trimester
Peds: NO
Clinical Consideration:
- Do not abruptly stop = rebound hypertension, tachycardia, MI
- Taper over 1-2 weeks
Propranolol
Drug Class Indication #4 MOA Caution #3 Contraindication #2 Clinical Consideration
Drug Class: nonselective beta blocker
Indication:
- afib/HTN/stable angina
- essential tremor
- Migraine prophylaxis
- Thyroid storm
MOA:
-Blocks beta1 & beta2
Caution:
- DM
- PVD
- hyperlipidemia
Contraindication:
- heart block
- Asthmatics
Clinical Consideration:
-Do not abruptly stop
Which selective beta blocker has the longest half life?
Atenolol; Qdaily dosing
Which betablocker can be used to treat preeclampsia?
Labetalol
Most antiepileptic drugs, such as perampanel, carry an increased risk of suicidal behavior or ideation. In addition to this adverse effect, which other psychosocial precaution is included for perampanel?
boxed warning for changes in mood, including hostility, aggression, and homicidal ideation.
Which phenobarbital result suggests that it is in the therapeutic range?
The therapeutic range for phenobarbital is 12 to 40 mcg/mL.
Cholinergic blockers are useful adjuncts early in the course of Parkinson’s disease to control tremor by relaxing smooth muscle and to control oral secretion, where drooling can be an issue. Which of these could potentially worsen Parkinson’s symptoms if given concurrently with levodopa?
Trihexyphenidyl
levodecreases the total bioavailability of levodopa, requiring an adjustment in dosage or risk potential worsening of Parkinson’s disease.
Which medication would both reduce the pain relief of a pure opioid and initiate an abstinence syndrome if given to a narcotic-addicted patient?
Pentazocine (Talwin)
A mixed agonist-antagonist will block the mu receptor, prompting an abstinence syndrome. Its antagonism will also reduce the pain relief of a pure opioid.
Which adverse drug reaction to a selective alpha1 antagonist would be the best reason to change to a different class of medication?
Impotence
The leading cause of nonadherence to a treatment regimen with alpha1-adrenergic antagonists is inhibition of ejaculation and impotence. These reactions should be reported to the health-care provider, who may choose a different drug to treat the disorder or change the dosage.
Which medications are first-line agents to treat Parkinson’s disease in its mild to moderate stages?
Bromocriptine, pergolide, pramipexole, or ropinirole are first-line agents in treating mild to moderate Parkinson’s disease.
Entacapone is an agent that is given with levodopa and carbidopa to reduce the “wearing off” effect. Levodopa is reserved as symptoms worsen because it is the cornerstone of Parkinson’s disease management, yet it has a “wearing off” effect. Therefore, entacapone would not be used early in treatment.
he APN is considering an antiepileptic drug for a patient suffering from partial seizures. Prescribing zonisamide will be avoided if the patient has a known anaphylactic reaction to which drug?
Bactrim and zonisamide are both sulfa drugs and chemically related. Sulfonamides should not be given to patients with a history of hypersensitivity.
Which medication has shown positive effects in the treatment of Alzheimer’s disease for at least 2 years?
Donepezil (Aricept), galantamine, memantine (Namenda), and rivastigmine (Exelon) have shown positive effects for at least 2 years
A 22-year-old female patient with bipolar disorder is treated with valproate (Depakote). She has a positive human chorionic gonadotropin (hCG) test. Which action taken by the APN is most appropriate?
Change the valproate to a nonclassified mood stabilizer and avoid the first trimester.
Valproate is associated with neural tube defects including spina bifida. It is Pregnancy Category D and should be restricted unless absolutely necessary and beyond the first trimester.
Which known adverse reaction to a cholinergic blocker would be considered most problematic?
Decreased sweating can put patients at risk for hyperthermia during warmer months and strenuous activity.
Bethanechol is contraindicated in the presence of which disease?
Bethanechol can cause excessive secretion of gastric acid, which could intensify gastric erosion and precipitate gastric bleeding and possible perforation.
Which cholinergic blocker must be taken with food?
Benztropine
Which of these describes the mechanism of cholinergic blockers?
Cholinergic blockers prevent the receptor from being activated.
Cholinergic blockers prevent interaction of endogenous neurotransmitters from activating the receptor and thereby block the action associated with stimulation of these receptors.
Seizures for a 25-year-old female patient with epilepsy have been managed best with oral phenytoin (Dilantin). The patient has just discovered she is pregnant. Which measure can reduce teratogenesis to the fetus?
Administration of daily oral folic acid
A 45-year-old patient is suffering from back pain due to severe muscle spasms. A centrally acting muscle relaxant, tizanidine (Zanaflex), is prescribed. By which mechanism of action does tizanidine act?
Binding to alpha2 adrenergic receptors, which increases the presynaptic motor neuron inhibition and reducing spasticity
A patient has poor appetite and some malabsorption tendencies. The APN wants to prescribe a cholinesterase inhibitor for its central nervous system (CNS) effects but knows that most require food for better availability. Which cholinesterase inhibitor is most appropriate for this patient?
Food has no effect on the absorption of donepezil, and the first-pass effect is greater than or equal to 90% bioavailability. Donepezil is also concentrated in the CNS.
The pharmacodynamics of selective alpha1 antagonists prevents them from being frontline treatment of hypertension. Which of these is the best reason to limit the use of selective alpha1 antagonists for treating hypertension?
All the “azosin” drugs are contraindicated in the presence of VOLUME DEPLETION.
Peripheral vasodilation caused by these drugs decreases venous return to the heart and may precipitate significant heart failure (HF). Several of the drugs are associated with fluid retention that may exacerbate HF.
Which malignant neoplasm is carbidopa-levodopa known to activate?
Melanoma
The patient has been having some issues with memory loss, and the APN suspects some components of early Alzheimer’s disease. The APN wants to start the patient on a cholinesterase inhibitor. The patient also has some history of elevated liver enzymes and questions of a fatty liver remain. Which of these should be avoided based on clearance?
Galantamine is extensively metabolized by CYP 2D6 and 3A4 isoenzymes, and clearance is decreased by about 25% in patients with moderate hepatic impairment.
A 3-year-old patient with Lennox-Gastaut syndrome is being treated with valproate sodium, but seizures are not well controlled. Lamotrigine (Lamictal) is being started as adjunctive therapy. Which serious adverse drug reaction is more risky when lamotrigine is coadministered with valproate sodium?
Lamotrigine has a Black Box Warning of SJS and toxic epidermal necrolysis. This risk is higher for pediatric patients. Coadministration with valproate increases this risk.
Activation of central alpha2 receptors results in inhibition of cardioacceleration and vasoconstriction centers in the brain. This action causes a decrease in peripheral outflow of norepinephrine (NE), leading to which effect?
The decreased peripheral outflow of NE leads to decreases in peripheral resistance, renal vascular resistance, heart rate, and blood pressure.
Many common clinically useful actions of adrenergic antagonists result from their action on alpha1 and beta1 receptors at different locations in the body. Which of these is a common cause of clinically useful action of adrenergic antagonists?
Blockade of alpha1 receptors at the bladder, neck, and prostate gland
Blockade of alpha1 receptors at the bladder and prostate gland will help in reduction of smooth muscle contraction, reducing outflow obstruction, and is a mechanism that commonly results in a clinically useful action of an adrenergic antagonist.
“-zosins”
Doxazosin, tamsulosin or terazosin
MOA HTN vs BPH ADR #7 Caution #2 Contraindication preg/lact Clinical Consideration #2
MOA:
Relieve outflow obstruction of BPH/ inhibit smooth muscle contraction
HTN: Inhibits postsynaptic alpha-1 receptors = vasodilation & decrease TPR & BP
BPH: Inhibit postsynaptic alpha-1 receptors in prostate & bladder neck = reduce tone induced urethra stricture
ADR:
- Fluid retention
- nasal congestion
- Orthostatic hypotension (first dose effects)
- Reflex tachycardia
- H/A
- Impotence
- Priapism (rare)
Caution:
- HF/angina/recent MI (fluid retention)
- elderly (risk of falls with hypotension)
Contraindication
-Volume depletion
Pregnancy/lact: NO!
Clinical Consideration:
- Prescribe for at night
- Educate patient that 1st dose effects might happen if they miss some doses
Which alpha-1 selective antagonist does not cause orthostatic hypotension?
Tamsulosin (flomax)
Which alpha-1 selective antagonist would be best for an elderly person with BPH?
Tamsulosin
What are Alpha 1 receptors associated with? What are they used for?
Stimulation of GU sphincter.
Used mostly for BPH and mild BP benefit
Clonidine (Catapres)
Drug Class Indication MOA ADR #5 Caution #3 Contraindication Patient education
Drug Class: Alpha-2 Agonist (Central)
Indication: HTN, ADHD
MOA:
HTN: stimulate Alpha2 in brainstem to activate inhibition = Reduced Sympathetic response from CNS “downregulates
ADHD: regulates prefrontal activity
ADR:
- Drowsy/Dry mouth
- Bradycardia
- Nightmares
- Impotence
- Constipation
Caution:
- Elderly (bradycardia/orthostatic hypotension)
- Coronary Insufficiency
- CVD
Contraindication:
- History Bradycardia
- Beta blockers (bradycardia)
Patient Education:
-Do not stop abruptly dd/t downregulation»_space;> rapid increase in BP
Methyldopa
Drug Class Indication MOA ADR #6 Caution#2 Contraindication#2 Clinical Consideration #2 pregnancy/lact peds
Drug Class: Alpha-2 Agonist
Indication: HTN
MOA: Stimulate central alpha-2 receptors via metabolite alpha-methylnorepinephrine
ADR:
- Edema
- Sedation
- Bradycardia/Hypotension
- elevated LFTs
- blood dyscrasias (rare)
- Hepatoxicity (rare)
Caution:
- Severe coronary insufficiency
- Cerebrovascular disease
Contraindication:
- history bradycardia
- Active renal/liver disease
Clinical Consideration:
- Tolerance may need to add diuretic
- Avoid with Beta blockers (bradycardia)
Pregnancy/Lact: no
Peds: NO
Metoprolol; Atenolol
Drug class Indication MOA ADR #5 Caution #3 Contraindication #3 Peds Clinical Considerations #2
Drug Class: Selective Beta blocker
Indication: HF HTN Afib Angina, post MI
MOA:
-Block beta-1
ADR:
- Hypertension
- Bradycardia
- Dizzy, fatigue*
- depression
- Impotence/decreased libido
Caution:
- PVD
- DM (Masks symptoms of hypoglycemia except for sweating)
- Hyperlipidemia (decreases HDL, Increases cholesterol)
Contraindication:
- History bronchospasm
- Heart Block
- Pregnancy 1st trimester
Peds: NO
Clinical Consideration:
- Do not abruptly stop = rebound hypertension, tachycardia, MI
- Taper over 1-2 weeks
Propranolol
Drug Class Indication #4 MOA Caution #3 Contraindication Clinical consideration #2
Drug Class: nonselective beta blocker
Indication:
- afib/HTN/stable angina
- essential tremor
- Migraine prophylaxis
- Thyroid storm
MOA:
-Blocks beta1 & beta2
Caution:
- DM
- PVD
- hyperlipidemia
Contraindication:
-heart block
Clinical Consideration:
- Do not abruptly stop
- Not for asthmatics = bronchospasm
Which selective beta-blocker has the longest half-life?
Atenolol; Qdaily dosing
Which beta-blocker can be used to treat preeclampsia?
Labetalol
Carvedilol
Indication #3 MOA ADR #4 Caution #3 Contraindication #4 Preg/lact
Indication:
- HFrEF
- LV dysfx after MI
- HTN
MOA:
-Nonselective BB & alpha-1 receptor blocker = Decrease BP & Peripheral resistance
ADR:
- Hypotension
- Dizzy/fatigue
- Hyperglycemia
- Impotence
Caution:
- PVD
- DM
- Hyperlipidemia
Contraindication:
- Bronchospasms
- Hepatic impairment
- Heart Block
- Class 4 HF
Pregnancy/Lact: NO
Labetalol
Indication MOA ADR Contraindication #2 Pregnancy Patient Education Clinical Considerations
Indication: Severe acute hypertension; preeclampsia
MOA:
-nonselective BB & Alpha-1 blocker
ADR:
- *Same as carvedilol**
- Hypotension
- Dizzy/fatigue
- Hyperglycemia
- Impotence
Contraindication:
- Bronchospasms
- Liver impairment
Pregnancy: after first trimester OK!!!!
Patient Education:
-Take with food
Clinical Consideration:
-Do not abruptly withdraw
Epinephrine
Indication MOA ADR Caution Pregnancy/lact/peds
Indication: Emergency Type 1 Allergic Reaction
MOA:
- Vasoconstriction
- Decreases vascular permeability
- Relaxes smooth muscle/broncho
ADR:
- Anxiety/tremor/palpitations/angina
- Alterations in blood sugar
- disorientation
Caution:
-CVD
Pregnancy/Lact/Peds: OK
Parasympathomimetics promote or mimic the action of which neurotransmitter?
Acetylcholine
Cholinergic agonists, also known as parasympathomimetics or muscarinic agonists, promote or mimic the action of acetylcholine (ACh), the neurotransmitter of the parasympathetic nervous system.
A patient comes into the practice complaining of worsening depression, anxiety, and strange dreams. The patient was just started on clonidine for poorly controlled hypertension. In reviewing the medication list, the APN sees that the patient is on both a tricyclic antidepressant and a low-dose antipsychotic. The vital signs show a sitting and standing blood pressure of 188/100 mm Hg. Which is the best course of action?
Taper the clonidine down and consider alternative therapy when done.
Central alpha2 agonists can worsen the sedative effects of central nervous system (CNS) depressants, be less effective in the face of tricyclic antidepressants, and worsen psychosis of those being treated.
Which component is most important for the APN to include in patient education on beta blockers?
Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension (HTN,) and myocardial ischemia. This is the most important component of patient education on beta blockers, because it can be immediately life threatening.
What happens with abrupt withdrawal of betablockers
life-threatening arrhythmias, hypertension (HTN,) and myocardial ischemia.
What are the signs of phenytoin hypersensitivity syndrome?
Fever
Skin rash
lymphadenopathy
Occurs at 3 to 8 weeks
What is the first line treatment for seizures?
Dilantin (Phenytoin)
Which pharmacokinetics are unique to levetiracetam compared with other antiepileptic drugs?
It is unbound, metabolized by hydrolysis, and does not use CYP450 enzymes.
These characteristics make levetiracetam almost devoid of drug-drug interactions
A patient with early-onset Alzheimer’s disease has come into the clinic and is concerned about some of the side effects that the cholinesterase inhibitors have. Which inhibitor would be the most appropriate choice?
Memantine
Memantine is the most appropriate choice, because it does not have the same precautions as the other drugs in its class.
Galantamine Donepezil & Rivastigmine few adverse reactions. Caution is indicated for patients with a history of bronchospastic disorders, peptic ulcer disease, cardiovascular diseases that may worsen in the presence of hypotension or bradycardia, and hyperthyroidism.
Which classification of drugs are inappropriate for use in the geriatric population?
Centrally acting alpha2 agonists
Centrally acting alpha2 agonists cause a reduction in sympathetic tone that can lead to possible rapid drop in blood pressure, contributing to orthostatic hypotension and falls. They are not appropriate for use in the geriatric population.
A patient has issues with poor appetite and some malabsorption tendencies. The APN wants to prescribe a cholinesterase inhibitor for its central nervous system (CNS) effects. However, the APN knows most of these drugs require food for better bioavailability. Which cholinesterase inhibitor is most appropriate for this patient?
Donepezil
Food has no effect on the absorption of donepezil, has a bioavailability of 90%, and has the greatest CNS concentration of the drugs listed.
Which of these would the APN include in patient education for central alpha2 receptor medications?
These drugs must be withdrawn slowly over 2 to 3 days to prevent rebound hypertension.
Cholinesterase inhibitors have possible effect on the sinoatrial (SA) and atrioventricular (AV) nodes in the heart, and bradycardia is an issue. This is especially prevalent in the older population. If a patient presents with a clear need for a cholinesterase inhibitor and has a cardiac history that includes drugs such as furosemide, digoxin, and warfarin, which medication would be the most appropriate choice for this patient?
Donepezil does not interact with furosemide, digoxin, or warfarin, which are drugs often prescribed for older adults who are also likely candidates for donepezil.
Rivastigmine, Neostigmine Memantine are not safe to take with these drugs
When considering cholinesterase inhibitors as treatment, which disease state would absolutely require a provider to find an alternative to treatment?
These medications could exacerbate this condition, leading to adverse bladder and kidney issues.
Which medication would most likely result in maximum central nervous system (CNS) effect?
Propranolol has the highest CNS penetration.
What is a Black Box Warnings for SSRI?
SI for people younger than 24 years
What is first line for Syphillis?
Penicillin
What is first line for BV?
Flagyl
What is 1st line for BV and Pregnancy
Clindamycin
What is the BBW for depo shot?
Osteoporsis with use for more than 2 years
Chlamydia 1st line
Azithromycin (Macrolides)
CAP 1st line
Azythromycin (Macrolides)
Pertussis 1st line
Azithromycin
Keppra ADR & education & clinical consideration
ADR
- somnolence/mood changes
- Derm reaction
- Blood dyscrasias
Education:
No Abrupt withdrawal = rebound seizures
Considerations:
not metabolized by liver so few drug to drug interactions
Safe for contraception
UTI first line
Macrobid or Bactrim
UTI pregnancy
Augmentin
BV 1st line
Flagyl
BV pregnant
Clindamycin
Allopurinol is safe for lactation? chronic or acute gout?
ADR #5
high risk for…?
How long to see effects?
yes
Chronic gout
Rash Arthralgia diarrhea hepatoxicity Hypersensitivity
High risk for SJS
1 week to see effects
what is the goal of cholinesterase inhibitors?
Prevent the degradation of acetylcholine
Cholinesterase drug interactions
ADR
Caution
CYP450 Anticholinergic drugs (drug is a cholinergic agonist)
ADR:
Dizzy
Agitation
Tremor
Caution:
Seizures
QT prolongation
What are signs of steven johnson syndrome
flu like
rash
blisters
