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701 neuro/psych/sub abuse > Week 2 > Flashcards

Week 2 Flashcards

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1
Q

Dementia

A
  • Progressive decline of intellectual ability from a previously attained level (baseline)
  • Deterioration of speech, memory, judgement and mood
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2
Q

1 Risk Factor for Alzheimer’s/Dementia

A

Age

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3
Q

Most common forms of Dementia

A
  • Alzheimer’s (70%)
  • Over 85 years; Both Alzheimer’s and Vascular Dementia
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4
Q

Vascular Dementia

A
  • Impaired cognition due to multiple ischemic events to the brain (strokes)
  • May present from sub-clinical strokes (lacunar)
  • **Involves stepwise decline
  • African Americans, Japanese, elderly with comorbidities at higher risk
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5
Q

Alzheimer’s Disease

A
  • Progressive, neurodegenerative disorder affecting cognition and behavior
  • Slow decline over time (not stepwise)
  • **Impairment in activities of daily living
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6
Q

Warning signs for Alzheimer’s

A
  • Problems with words/speaking
  • Poor judgement
  • Withdrawal from social/work life
  • Changes in mood/personality
  • Memory loss that disrupts daily life
  • Problems with visual and spatial relationships
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7
Q

Apolipoprotein E4 (APOE4)

A

Factor associated with family risk of Alzheimer’s (not well understood)

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8
Q

Mild Cognitive Impairment (MCI)

A

Impaired cognition, memory or behavior WITHOUT impairment of daily activities

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9
Q

Mini-Mental Status Scores (not sure if we need to know)

A

> 26 - Normal
20-26 - Mild Dementia
12-20 - Moderate Dementia
<12 - Severe Dementia

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10
Q

Alternative sources to cognitive impairment

A
  • B12 deficiency
  • Normal Pressure Hydrocephalus (NPH)
  • Hypothyroidism
  • Infections (HIV, UTIs in elderly)
  • Anticholinergics in elderly
  • Alcoholism/Chronic drug intoxication
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11
Q

Areas of brain involved in Alzheimer’s

A
  • Cerebral cortex (atrophy/shrinks)
  • Hippocampus (converts short term memories to long term)
  • Amygdala
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12
Q

Anticholinergics associated with Alzheimer’s in the elderly

A
  • Antihistamines (Doxylamine, Benadryl)
  • **Cimetidine (#1 OTC)
  • TCAs (Amitriptyline, Cyclobenzaprine)
  • Bladder Meds (Oxybutynin)
  • Antiemetics (Meclizine, Scopolamine, Prochlorperazine)
  • Antipsychotics (Clozapine, Chlorpromazine, Thioridazine)
  • Codeine
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13
Q

What is concern for Anticholinergics with elderly in Alzheimer’s?

A
  • Marked decrease in ACh in ALZ pts
  • ACh plays role in memory formation
  • Exposure to anticholinergics 10 years prior to dementia diagnosis associated with dementia AND risk does NOT go away when drug is D/C’d
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14
Q

Non-pharm therapies for ALZ

A
  • Memory books/notes
  • Environmental changes (quiet, well-lit rooms)
  • Exercise/ Occupational therapy
  • Cognitive Rehab (early stages only)
  • Support groups
  • Pt input on health choices prior to loss of judgement (power of attorney, proxy, will, etc.)
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15
Q

Medication classes for memory

A
  1. Acetylcholinesterase inhibitors
  2. Memantine
  3. Anti-amyloid agents
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16
Q

Treatments for behavior

A
  1. Non-pharm therapies 1st line
  2. Antidepressants/anxiety/psychotics (*Black box warning for antipsychotics : increased mortality in dementia elderly pts)
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17
Q

Donepezil (Aricept)

A
  • AChE inhibitor
  • Indicated for mild to severe AD
  • 5 mg daily for 4-6 weeks (can inc to 10mg or 23mg if desired)
  • CYP2D6/3A4 metabolite
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18
Q

Donepezil ADEs

A
  • Bradycardia
  • Rhabdomyolysis and/or neuroleptic malignant syndrome (v. rare)
  • Less GI effects but more sleep disturbances than other drugs in class
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19
Q

Rivastigmine (Exelon)

A
  • AChE inhibitor
  • Indicated for mild to severe AD and mild to moderate Parkinson’s dementia
  • NOT metabolized by CYP (only AChEi)
  • Tabs: 6-12 mg/day given BID
  • Patch: 4.6mg/day for 4 weeks (increase to 9.5mg if tolerated)
  • Patch should ONLY be applied to back, arms and chest for best absorption
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20
Q

Rivastigmine ADEs

A
  • Tabs: GI issues (require slow titration, take with food)
  • Patch: site reactions (less GI vs tabs)
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21
Q

Galantamine (Razadyne)

A
  • AChE inhibitor
  • Indicated for mild to moderate AD
  • IR: 4mg BID for 4 weeks (inc to 8,12)
  • ER: 8mg daily for 4 weeks (inc to 16, 24)
  • Should NOT be used in hepatic/renal failure
  • CYP2D6/3A4 metabolite
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22
Q

Memantine (Namenda)

A
  • NMDA receptor antagonist
  • Approved for moderate to severe AD
  • Not metabolized by CYP enzymes
  • **CL significantly reduced by alkaline urine (caution with meds/diet in urine pH)
  • IR: 5mg daily (target dose 20mg)
  • ER: 7mg daily (target dose 28mg)
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23
Q

Memantine Precautions

A
  • History of seizure disorder (increased risk of seizures)
  • Cardiovascular disease (increased incidence of cardiac failure, angina, bradycardia and HTN)
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24
Q

Memantine ADEs

A
  • Dizziness
  • Constipation (AChEi cause diarrhea, may help offset if on both together)
  • Issues with balance
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25
Q

Hallmark Pathology signs of AD in the brain

A
  1. Beta-amyloid plaques (disrupts neurons, affects hippocampus and cerebral cortex)
  2. Neurofibrillary tangles (tau destabilizes leading to microtubule collapse and cell structure failure)
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26
Q

Aducanumab (Aduhelm)

A
  • Anti-amyloid therapy (directed against aggregated soluble/insoluble amyloid beta)
  • Partially FDA approved due to 1 of 2 trials showing no clinical improvement
  • Indicated for MCI or mild AD
  • 10 mg/kg IV infusion every 4 weeks
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27
Q

Anti-Amyloid Precautions/ADEs

A
  • **Boxed warning for ARIA (Amyloid related imagining abnormalities)
  • ARIA-E: vasogenic edema or sulcal effusions/exudates
  • ARIA-H: microhemorrhages or hemosiderosis
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28
Q

Symptoms of ARIA

A

Usually asymptomatic but present on scan
- Headache
- Confusion/delirium/AMS
- Dizziness/vertigo
- Visual disturbances/Nausea

D/C drug therapy if moderate to severe on MRI regardless of symptoms

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29
Q

Lecanemab (Leqembi)

A
  • Anti-amyloid therapy
  • Received FULL FDA approval (slowed disease progression by 27% ~ 7 months)
  • 10 mg/kg IV every 2 weeks
  • Boxed warnings for ARIA
  • ADEs: Infusion related reactions
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30
Q

What are migraines

A

At least 5 attacks with:
- Headaches lasting 4-72 hours
- Headaches that are (at least 2/4) unilateral, pulsating, moderate/severe pain intensity, are aggravated by or cause by physical activity
- During headache, have photophobia/phonophobia and/or nausea/vomiting

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31
Q

What are TIAs

A
  • Visual loss
  • Abrupt
  • Simultaneous occurrence
  • Duration < 15 minutes
  • Headache is an uncommon accompaniment
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32
Q

Migraine pharmacotherapy principles

A
  • Acute treatment is more effective if given early in the course of a headache
  • A large single dose is better than small, repetitive doses
  • Counsel patients on medication overuse headache
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33
Q

Options for mild-moderate migraine attacks

A
  • NSAIDs
  • Acetaminophen
  • Caffeinated analgesic combinations (non-opiate!)
34
Q

Options for moderate-severe migraine attacks or refractory mild-moderate migraine attacks

A
  • Triptans
  • DHE
  • Gepants/ditans (if triptans are not tolerated/contraindicated)
35
Q

NSAID options

A

Diclofenac potassium oral solution
- Powder form - mix in 2-4 TBSP of water
Celecoxib oral solution

Can be used in adults with/without aura

36
Q

Butalbital/Caffeine/APAP

A
  • BBW for hepatoxicity
  • Non-controlled
  • Indicated for tension HA, but used for migraines
  • 50 mg butalbital, 300-325 mg APAP, 40 mg caffeine
  • AE: CNS depression, stomach upset
  • Common for medication overuse headache
37
Q

Butalbital/Caffeine/ASA

A
  • CIII
  • Indicated for tension HA, but used for migraines
  • 50 mg butalbital, 325 mg ASA, 40 mg caffeine
  • AE: CNS depression, stomach upset
  • Common for medication overuse headache
38
Q

Triptans

A
  • Administer early in the course of a migraine attack to improve treatment response
  • AE: flushing, chest pain, palpitations, dizziness, fatigue, xerostomia, serotonin syndrome
  • Limit use to less than 10 days per month (medication overuse headache)
  • Caution in older adults
  • May combine with NSAIDs
39
Q

Triptan CIs

A
  • Hemiplegic migraine or migraine with brainstem aura
  • Known/suspected ischemic heart disease/ CV disease
  • Wolff-Parkinson-White syndrome or arrhythmias
  • Stroke, TIA
  • Peripheral vascular disease (including ischemic bowel disease)
  • Uncontrolled hypertension
  • Use within 24 hours of an ergotamine preparation or other triptan
  • MAOIs (with riza, suma, and zolmi)
40
Q

Triptans with the longest half life?

A

Frovatriptan (26 hours)
Naratriptan (6 hours)

41
Q

Triptan CI with potent 3A4 inhibitors

A

Eletriptan

42
Q

Triptan with an SQ, PO, and Intranasal route of admin

A

Sumatriptan

43
Q

Triptan with a PO and intranasal route of admin

A

Zolmitriptan

44
Q

Triptan with the quickest onset of action

A

Sumatriptan SQ (10 mins!)
Then sumatriptan intranasal (15-30 minutes)

45
Q

Lasmitidan (Reyvow)

A
  • CV
  • Max of one dose per day
  • Use not recommended in severe hepatic impairment
  • Must wait at least 8 hours between dosing and operating heavy machinery or driving
    AE: CNS depression, serotonin syndrome, decreased HR, increased BP, palpitations, dizziness, nausea, vomiting
46
Q

Rimegepant (Nurtec)

A
  • PO ODT
  • Acute AND preventative treatment for migraine
  • Prevention dose is every other day
  • Avoid use in severe hepatic impairment and CrCl < 15 mL/min
  • Onset of action < 2 hours
  • AE: abdominal pain, dyspepsia, nausea
47
Q

Ubrogepant (Ubrevly)

A
  • PO tablet
  • Acute treatment in adults with/without aura
  • Can repeat a dose after 2 hours
  • Contraindicated with strong 3A4 inhibitors
  • Dose reduction CrCl <30 mL/min, avoid < 15 mL/min
  • Dose reduction with severe hepatic impairment
    AE: nausea, drowsiness, xerostomia
48
Q

Anti-migraine ergots

A
  • BBW: contraindicated with potent CYP3A4 inhibitors, including protease inhibitors, macrolide antibiotics, and azole fungals
  • AE: Cardiac valvular fibrosis, ergotism, serotonin syndrome
  • Do not use in pregnancy or breastfeeding
  • Do not use within 24 hours of triptans, other serotonin agonists, or ergotamine-containing or ergot-like agents
    -Monitoring: renal and liver function, cardiovascular status
49
Q

Ergotamine

A
  • Not recommended in older adults
  • AE: nausea, vomiting, ECG changes, hypertension, ischemia, vasospasm, numbness, paresthesia, gangrene
  • D/C may result in withdrawal symptoms, such as rebound headache
  • Interaction with grapefruit juice (increased levels)
  • May worsen nausea/vomiting with headache
50
Q

Dihydroergotamine

A
  • Injection: cluster headaches and migraine
  • NS: migraine
  • Fewer side effects than ergotamine
  • CI: ischemic heart disease, coronary artery vasospasm, following vascular surgery, concurrent use of peripheral and central vasoconstrictors, NS is contraindicated with brainstem aura or hemiplegic migraine
  • Do not use within 24 hours of another ergotamine or triptan
  • Monitoring: CAD risk factors, cardiovascular evaluation
51
Q

Severe migraine treatment in the ED

A

IV/IM dexamethasone
SQ sumatriptan
IV prochlorperazine + diphenhydramine
IV metoclopramide + diphenhydramine
IV chlorpromazine + diphenhydramine
IV DHE + antiemetic
IV valproate
IV/IM ketorolac
IV magnesium

52
Q

When to give preventative migraine treatment

A
  • Attacks significantly interfere with patient’s daily routines despite acute treatment
  • Frequent attacks
  • Contraindication to, failure, or overuse of acute treatments
  • AEs with acute treatments
  • Patient preference
53
Q

Topiramate

A
  • Prevention of migraine
  • AE: cognitive dysfunction, CNS effects, nephrolithiasis, metabolic acidosis, angle-closure glaucoma, oligohidrosis/hyperthermia, suicidal ideation, weight loss, paresthesia
  • Counsel on importance of hydration
  • Avoid in pregnancy
54
Q

Valproic acid

A
  • BBW: hepatotoxicity, patients with mitochondrial disease, fetal risk, pancreatitis
  • Migraine prevention
  • AE: CNS effects, hepatotoxicity, encephalopathy, TEN, SJS, DRESS, pancreatitis, suicidal ideation
  • CIs: Prevention of migraine in pregnant women and women of childbearing potential who are not using effective contraception, severe hepatic impairment, mitochondrial DNA polymerase gamma mutation-associated mitochondrial disorders
55
Q

Beta-Blockers

A

Propranolol, timolol are indicated for prevention of migraine

56
Q

Tricyclic antidepressants

A

Amitriptyline, nortriptyline
- BBW: suicidality
- Lower initial doses for migraine prevention than for MDD
AE: anticholinergic effects, CNS depression, cardiac conduction abnormalities, orthostatic hypotension, serotonin syndrome

57
Q

Venlafaxine

A
  • BBW: suicidality
  • AE: CNS depression, weight loss, anorexia, increased blood pressure, hepatotoxicity, hyponatremia, acute angle-closure glaucoma, serotonin syndrome
58
Q

Atogepant (Qulipta)

A
  • Preventative treatment of episodic migraine in adults
  • Once daily doses
  • Not recommended for use in severe hepatic impairment
  • Dose reduction CrCl < 30 mL/min
    AE: constipation, nausea, drowsiness, fatigue, weight loss
59
Q

CGRP monoclonal antibodies

A

Caution in patients with recent cardiovascular or cerebrovascular ischemic events

60
Q

Eptinezumab (Vyepti)

A
  • CGRP ligand
  • IV Q3M
  • AE: infusion reactions, nasopharyngitis, nausea
61
Q

Erenumab (Aimovig)

A
  • CGRP receptor
  • SQ QM
  • AE: injection site reactions, constipation
62
Q

Fremanezumab (Ajovy)

A
  • CGRP ligand
  • SQ QM or Q3M
  • AE: injection site reaction
63
Q

Galcanezumab (Emgality)

A
  • CGRP ligand
  • SQ QM
  • AE: Injection site reaction
64
Q

Peripheral nerve blocks

A

Use lidocaine and/or bupivacaine and/or methylprednisolone

65
Q

Non-pharm treatments for migraine

A

Stress reduction techniques
Dietary changes
Trigger avoidance
Magnesium
Vitamin B2
Feverfew
Butterbur
Neuromodulation devices

66
Q

PO Magesium

A
  • Migraine prophylaxis
  • AE: diarrhea, N/V
67
Q

Vitamin B2

A
  • Migraine prophylaxis
68
Q

Feverfew

A
  • Migraine prophylaxis
  • Avoid use in pregnancy
    AE: GI (stomach pain, bloating, constipation, diarrhea, flatulence, heartburn, nausea)
69
Q

Butterbur

A
  • Migraine prophylaxis
  • Avoid products that are not labeled as free from Pyrrolizidine alkaloids
  • AE: GI (belching, diarrhea, stomach upset), drowsiness, fatigue, pruritis, rash, hepatotoxicity
70
Q

Botox

A
  • Neurotoxin that prevents calcium-dependent release of ACh and produces a state of denervation
  • BBW: spread of toxin effect
  • Indicated for prevention of chronic migraine headaches in adults (>15 days per month with headache lasting > 4 hours per day)
  • Administered Q12W
  • AE: injection site pain, neck pain, myalgia, facial paresis
71
Q

Menstrual migraines

A
  • Frovatriptan x 6 days
  • Naratriptan X 5-6 days
  • Zolmitriptan x 7 days
  • Magnesium
  • Acute treatments
  • COC (avoid with patients with aura)
72
Q

Special Populations

A

Acute migraine treatment for patients with cardiovascular/cerebrovascular disease: gepants and lasmiditain

Acute migraine treatment for pregnant patients: APAP

73
Q

Tension Headaches

A
  • 30 mins to 7 days in duration
  • Bilateral, pressing/tightening, mild-moderate intensity, not aggravated by physical activity
  • No N/V
  • NMT 1 of photophobia/phonophobia
74
Q

Tension headache therapies

A
  • Simple analgesics (NSAIDs, APAP)
  • Analgesics comboed with caffeine
  • Last line: Combo analgesics with butalbital or codeine (counsel on medication overuse headache)

Preventative: Antidepressants, anticonvulsants, trigger point injections

75
Q

Cluster headache treatment

A

Acute: oxygen, SQ or intranasal sumatriptan, intranasal zolmitriptan

Preventative: Verapamil (preferred!), glucocorticoids, galcanezumab, lithium, topiramate, greater occipital nerve blocks

76
Q

Hemicrania continua treatment

A

Indomethacin (preferred!) , Botox, occipital nerve stimulation, vagus nerve stimulation, peripheral nerve blocks

77
Q

Pseudotumor cerebri treatment

A

Withdraw offending agent
Weight loss
Carbonic anhydrase inhibitors (acetazolamide, topiramate)
Furosemide
Migraine preventive medications

78
Q

Medications associated with reversible cerebral vasoconstriction syndrome

A

SSRIs
Triptans
Ergots
Cyclophosphamide
Tacrolimus
Nasal decongestants
Illegal drugs
Others

79
Q

Symptoms of subarachnoid hemorrhage (life threatening emergency!)

A

Sudden or thunderclap onset of headache
Worst headache of their life
N/V
Photophobia
Neck stiffness
Focal neurologic deficits
Brief loss of consciousness

80
Q

Medication overuse headache causes

A

> 5 days per month: butalbital
10 days per month: triptans, opioids, anti-migraine ergots
15 days per month: non-opioid analgesics

Wean off or D/C, use bridge therapy, or initiate preventative and breakthrough therapy

81
Q

Substance withdrawal headache

A

Caffeine > 200mg/day for > 2 weeks
Opioids > 3 months

701 neuro/psych/sub abuse (2 decks)

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