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69 Cards in this Set
- Front
- Back
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List five dopamine agonists.
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Cabergoline
Bromocriptine Ropinerole Pramipexole Pergolide |
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For which question is a dopamine agonist the correct answer?
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Dopamine agonist are the correct medications for the following conditions:
1) Parkinson's disease; these meds are less potent but have fewer adverse effects when compared to levodopa/carbidopa 2) Restless leg syndrome: These medications are the best initial therapy. 3) Prolactinoma: These medications are the best initial therapy; they are better than surgery. |
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What are the adverse effects of dopamine agonist?
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Adverse effects caused by dopamine agonists are nausea, vomiting, sleepiness, orthostatic hypotension, confusion, and hallucinations. Pergolide was taken off the market because of adverse cardiac effects (valve regurgitition).
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When do you answer amantadine as the best initial therapy?
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Amantadine is the best initial therapy for the following conditions:
1) Acute influenza A: within 48 hours of the onset of symptoms. Amantadine is INFERIOR to oseltamivir. 2) Mild Parkinson's disease (PD). Mild PD is characterized predominantly by a tremor, and the patient retains the ability to perform activities of daily living. |
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How does amantadine work?
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Amantadine and rimantadine both inhibit the replication of the infuenza A virus. Amantadine also enhances dopamine release from the substantia nigra and prevents re-uptake.
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What are the most common adverse effects of amantadine?
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Amantadine may cause confusion, hallucinations, and nightmares. Depression and restlessness may occur as well. Livedo reticularis can also occur.
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A 45 yo woman is evaluated because of painful contracted muscles. There is marked hypertonicity and hyperreflexia.
What is the best therapy for her painful muscles? |
1) Baclofen and tizanadine can be used for her spasticity.
2) Diazepam and dantrolene can also be used but are less effective. |
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A 45 yo woman is evaluated because of painful contracted muscles. There is marked hypertonicity and hyperreflexia.
How does this treatment work? |
1) Baclofen is an analog of gamma aminobutyric acid (GABA). The precise mechanism of its effect in relieving spacticity is not known.
2) Tizanadine is centrally acting alpha adrenergic agonist but does not lower blood pressure. Tizanadine inhibits presynaptic motor neurons. |
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A 45 yo woman is evaluated because of painful contracted muscles. There is marked hypertonicity and hyperreflexia.
What are the adverse effects of this treatment? |
1) The adverse effects of baclofen are dizziness, lightheadedness, drowsiness, and weakness.
2) Tizanadine causes dizziness, lightheadedness, and dry mouth. |
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A 45 yo woman is evaluated because of painful contracted muscles. There is marked hypertonicity and hyperreflexia.
What medication should you give to prevent progression of her disease? |
The rate of progression of multiple sclerosis can be slowed with beta interferon and copolymer 1 (glatirimer).
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A man is evaluated for a motor neuron disease in which he has fasciculations, muscle wasting, hyperreflexia, weakness, and upgoing toes but intact cognition.
What medication can you give him to prevent progression of his disease? |
Amyotrophic lateral sclerosis (ALS) is the combination of upper and lower motor neurons dysfunction. There is weakness, wasting, hyperreflexia, and fasciculations but intact cognition, bowel, bladder, and sexual function. ALS progression can be slowed down by riluzole.
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A man is evaluated for a motor neuron disease in which he has fasciculations, muscle wasting, hyperreflexia, weakness, and upgoing toes but intact cognition.
How treatment for this work? |
Riluzole inhibits glutamate release presynaptically by blocking sodium channels.
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A man is evaluated for a motor neuron disease in which he has fasciculations, muscle wasting, hyperreflexia, weakness, and upgoing toes but intact cognition.
What are the most common adverse effects of this treatment? |
Riluzole can cause nausea, vomiting, weakness, and spasticity.
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When is lamotrigine the answer?
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Lamotrigine is used to treat the following conditions:
1) Seizure disorder, generalized and partial. 2) Peripheral neuropathy 3) Mood disorders, such as bipolar syndrome |
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A man comes to the ED because of sudden, sharp pain in this face that happened while he was eating. It started near the side of the mouth and progressed to the ear. It resolved after a few seconds and then recurred. Currently his sensory examination is normal.
What is the therapy for this patient? |
Carbamazepine is the best initial therapy for trigeminal neuralgia. It shoud be effective in more than 90 percent of cases. For those not responding, phenytoin, baclofen, or gabapentin may be effective. Surgery is performed if all medications fail.
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How does lamotrigine work?
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Lamotrigine blocks the repetitive firing of neurons by inactivating voltage-dependent sodium channels. It may selectively influence neurons that synthesize glutamate and aspartate.
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What are the most common adverse effects of lamotrigine?
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Lamotrigine can cause very severe skin reactions, such as Steven's Johnson syndrome.
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A man comes to the ED because of sudden, sharp pain in this face that happened while he was eating. It started near the side of the mouth and progressed to the ear. It resolved after a few seconds and then recurred. Currently his sensory examination is normal.
How does this treatment work? |
Carbamazepine works in a similar fashion as phenytoin. It blocks sodium channels at therapeutic concentrations and inhibits high frequency repetitive firing in neurons in culture. It also acts presynaptically to decrease synaptic transmission.
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A man comes to the ED because of sudden, sharp pain in this face that happened while he was eating. It started near the side of the mouth and progressed to the ear. It resolved after a few seconds and then recurred. Currently his sensory examination is normal.
For what other conditions is this therapy used? |
Carbamazepine is also effective as a first-line medications for seizures and for peripheral neuropathy.
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A man comes to the ED because of sudden, sharp pain in this face that happened while he was eating. It started near the side of the mouth and progressed to the ear. It resolved after a few seconds and then recurred. Currently his sensory examination is normal.
What are the most common adverse effects of this treatment? |
Carbamazepine can cause diplopia, ataxia, and hyponatremia. Rarely, it brings on aplastic anemia.
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When is levetiracetam the answer?
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Levetiracetam is effective in the treatment of seizures.
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How does levetiracetam work?
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Levetiracetam modifies the synaptic release of glutamate and GABA through action on vesicular function.
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What are the most common adverse effects of levetiracetam?
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Levitiracetam has virtually no adverse effects and does not require drug level monitoring. This is what makes the drug special. Some patients feel weak, sleepy, and dizzy.
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What is the best therapy for this patient?
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All of the medications listed below are acceptable as initial treatments for a generalized seizure. It is not clear which medications may be superior to others.
1) Valproate 2) Carbamazepine 3) Phenytoin 4) Lamotrigine 5) Oxycarbazepine 6) Phenobarbital 7) Topiramate |
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What are the most common adverse effects of this treatment?
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1) Valproate: weight gain, tremor, hepatotoxicity
2) Carbamazepine: Hyponatremia, lethargy, neutropenia 3) Phenytoin: gingival hyperplasia, hirsuitism 4) Lamotrigine: Stevens-Johnson syndrome 5) Oxcarbazepine: Vertigo, ataxia, hyponatremia 6) Phenobarbital: Sedation 7) Topiramate: glaucoma |
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A 62 yo man with diabetes comes to the office because he's been experiencing numbness and tingling in his feet for the last few months.
What is the best initial therapy for this patient? |
Either gabapentin or pregabalin is the best initial therapy for peripheral neuropathy, especially from diabetes or HIV. Both of these medications can be used as seizure medications as well.
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A 62 yo man with diabetes comes to the office because he's been experiencing numbness and tingling in his feet for the last few months.
How does this treatment work? |
Both gabapentin and pregabalin medications are analogs of GABA.
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A 62 yo man with diabetes comes to the office because he's been experiencing numbness and tingling in his feet for the last few months.
What are the most common adverse effects of the treatment? |
The most common adverse effects of gabapentin and pregabalin are somnolence, dizziness, ataxia, headache, and tremor.
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A 62 yo man with diabetes comes to the office because he's been experiencing numbness and tingling in his feet for the last few months.
What is the next step if initial therapy fails? |
Peripheral neuropathy is very difficult to treat. Most of the seizure medications, such as carbamazepine, valproic acid, and phenytoin, can effective for peripheral neuropathy. TCAs are also very effective against neuropathy but can cause dry mouth, urinary retention, and constipation because of their anticolinergic effects.
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List five Tricyclic Antidepressants.
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Amitryptyline
Imipramine Nortriptyline Desipramine Protriptyline |
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When are TCAs the answer?
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1) Major depression
2) OCD, phobia, and anxiety 3) Attnetion-deficit disorder 4) Chronic pain syndromes and peripheral neuropathies 5) Nocturnal enuresis 6) Migraine headache prophylaxis |
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How do TCAs work?
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TCAs block the reuptake of amine neutrotransmitters norepinephrine and serotonin, leaving more of the neurotransmitters in the synpses.
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What are the most common adverse effects of TCAs?
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TCAs cause many anticholinergic adverse effects, even at therapeutic doses, such as dry mouth, urinary retention, constipation, and orthostasis. At toxic levels, they cause QT prolongation, arrhythmias, and seizures.
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List two COMT inhibitors.
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Tolcapone
Entacapone |
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What are COMT inhibitors?
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Tolcapone and entacapone are catechol O-methyltransferase inhibitors that extend the duration of levodopa replacement and treat Parkinson's disease.
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How do COMT inhibitors work?
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COMT inhibitors prevent the degradation of levodopa. Levodopa is normally inactivated by COMT. They keep levodopa levels higher for longer. Entacapone and tolcapone cannot be used alone; they must accompany levodopa replacement.
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When are COMT inhibitors the answer?
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Answer COMT inhibitors when the question describes a Parkinson's patient with symptoms that are progressing despite increasing levodopa/carbidopa use.
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What are the most common adverse effects associated with COMT inhibitors?
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The adverse effects of COMT inhibitors are orthostatic hypotension, dyskinesia, confusion, and FATAL hepatic failure.
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A 72 yo woman comes to the office with a tremor and difficulty walking. She is able to take care of herself at home but does not like her increasing slowness of movement. She has mild cogwheel rigidity.
What is the best initial therapy for this patient? |
Mild parkinson's:
1) MAO inhibitors: selegilene, rasagilene 2) Tremor only: <70; anticholinergics trihexyphenidyl and benztropine >70; Amantadine 3) Moderate disease: Dopamine agonists; pramipexole and ropinerole. These have less potent, less adverse effects than levodopa replacement. Levodopa/Carbidopa; if levodopa replacement does not control symptoms, a COMT inhibitors is added. Severe is defined as the inability to take care of oneself or to be employed. |
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A 72 yo woman comes to the office with a tremor and difficulty walking. She is able to take care of herself at home but does not like her increasing slowness of movement. She has mild cogwheel rigidity.
How does this treatment work? |
Levodopa: carbidopa is added to block peripheral metabolism so more levodopa enters the brain.
Selegilene and rasagilene: block dopamine metabolism Amantadine: Increases dopamine release from substantia nigra. |
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A 72 yo woman comes to the office with a tremor and difficulty walking. She is able to take care of herself at home but does not like her increasing slowness of movement. She has mild cogwheel rigidity.
What are the most common adverse effects of this treatment? |
Levodopa: dyskinesia, the "on/off" phenomenon
Selegilene and rasagilene: Confusion; also, these meds interact with TCAs and SSRIs. Anticholinergics: Dry mouth constipation, and urinary retention. |
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What is ethosuxamide?
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Ethosuxamide is an antiseizure medication that is most effective for absence seizures.
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How does ethosuxamide work?
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Ethosuxamide reduces low-threshhold calcium currents in thalamic neurons. The thalamus plays an important role in generation of 3-Hz spike and wave rhythms typical of absence seizures.
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What are the most common adverse effects of ethosuxamide?
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Ethosuxamide's most common adverse effect is drowsiness.
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When is ethosuxamide the answer?
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Ethosuxamide is the answer to a question that describes a child who has 10 to 30 second periods of loss of consciousness. There can be eyelid fluttering, but the child does not fall or convulse. The child abruptly stops activity, then just as abruptly resume it. with no postictal symptoms or knowledge that a seizure has occurred. Absence seizures are genetic and occur predominantly in children.
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A 79 yo man is evaluated for increased forgetfulness and short-term memory loss. He has no focal neurological abnormalities. The head CT scan shows bilateral symmetrical atrophy. The B12 level, rapid plasma reagin, and thyroid function tests are normal.
What is the best initial therapy? |
The best initial therapy for Alzheimer's dementia is with donepezil, galantamine, or rivastigmine.
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A 79 yo man is evaluated for increased forgetfulness and short-term memory loss. He has no focal neurological abnormalities. The head CT scan shows bilateral symmetrical atrophy. The B12 level, rapid plasma reagin, and thyroid function tests are normal.
How does the best initial therapy work? |
Donepezil, galantamine, or rivastigmine are acetyl-cholinesterase inhibitors. They act in the CNS to increase the level of acetylcholine.
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A 79 yo man is evaluated for increased forgetfulness and short-term memory loss. He has no focal neurological abnormalities. The head CT scan shows bilateral symmetrical atrophy. The B12 level, rapid plasma reagin, and thyroid function tests are normal.
What are the most common adverse effects of the treatment? |
Cholinesterase inhibitors can cause diarrhea and mild nausea and vomiting. This is because acetylcholine acts as promotility agent for the gastrointestinal tract.
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What is capsaicin?
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Capsaicin is a cream that is used as an analgesic.
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How does capsaicin work?
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Capsaicin is derived from red peppers and inhibits the release of substance P from sensory fibers. Substance P causes pain.
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What are capsaicin's most common adverse effects?
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Capsaicin causes burning and erythema at the site of application.
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When is capsaicin the answer?
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Capsaicin is a second-line medication for the following:
1) Postherpetic neuralgia 2) Osteoarthritis 3) Rheumatoid arthritis 4) Diabetic neuropathy |
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A 25 yo woman comes to the ED for a unilateral throbbing headache. She is nauseated and notices some bright flashes of light. She has had several of these before. She takes oral contraceptives and is menstruating.
What is the best initial therapy for this patient? |
Migraine headaches are aborted by dihydroergotamine and ergotamine combined with caffeine or one of the triptans. Examples of triptans are sumatriptan, zolmitriptan, naratriptan, and elitriptan.
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A 25 yo woman comes to the ED for a unilateral throbbing headache. She is nauseated and notices some bright flashes of light. She has had several of these beofre. She takes oral contraceptives and is menstruating.
How does this therapy work? |
Triptans and ergotamine are serotonin agonists that constrict large vessels.
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A 25 yo woman comes to the ED for a unilateral throbbing headache. She is nauseated and notices some bright flashes of light. She has had several of these beofre. She takes oral contraceptives and is menstruating.
What are the adverse effects of treatment? |
Triptans can precipitate angina and myocardial infarction by constricting vessels. They are CONTRAINDICATED in coronary artery disease.
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A 25 yo woman comes to the ED for a unilateral throbbing headache. She is nauseated and notices some bright flashes of light. She has had several of these beofre. She takes oral contraceptives and is menstruating.
What would you do to prevent these symptoms from recurring? |
Migraine headaches are best prevented by the chronic use of beta blockers, such as propranolol. The other prophylactic medications for migraine are valproic acid, gabapentin, CCBs and TCAs
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A 60 yo man comes for several severe, unilateral, sharp headaches occurring over several days. They associated with tearing on the eye, redness of the eye, ptosis, constriction of the pupil, and rhinorrhea.
What is the best initial therapy? |
Cluster headaches are aborted by inhaling 100 percent oxygen. Migraine medications, such as sumatriptan or ergotamine, may be effective as well.
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A 60 yo man comes for several severe, unilateral, sharp headaches occurring over several days. They associated with tearing on the eye, redness of the eye, ptosis, constriction of the pupil, and rhinorrhea.
What can you give to prevent the next headache? |
Cluster headaches are best prophylaxed with the use of lithium or prednisone for several weeks. Beta blockers are not as good a choice. The therapeutic benefit of propranolol to prevent a headache takes several weeks to become evident, and the cluster will be over by the time the beta blocker becomes effective.
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A 34 yo man is admitted because severe lower extremity weakness which has developed over the past week. It started in his feet and has ascended to his upper legs. He recently had an episode of gastroenteritis. The deep tendon reflexes of his legs are absent. Electromyography and nerve condition studies are abnormal.
What is the best therapy? |
Guillain-Barre syndrome is treated with plasmapheresis or infusions of IVIG. There is no benefit to combined therapy. Steroids have no benefit.
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A 34 yo man is admitted because severe lower extremity weakness which has developed over the past week. It started in his feet and has ascended to his upper legs. He recently had an episode of gastroenteritis. The deep tendon reflexes of his legs are absent. Electromyography and nerve condition studies are abnormal.
What is the most likely cause of death from this patient's condition? |
Death from Guillain-Barre occurs from progression to involvement of the respiratory muscles. Monitoring of the vital capacity is needed to determine if a patient needs intubation.
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A man comes to the ED after a continuous seizure for the last 30 minutes. There has been no response to repeated injections of benzodiazepines (lorazepan, diazepam).
What is the next best step in management? |
Phenytoin or fosphenytoin is used to treat status epilepticus that has not responded to benzodiazepines. Fosphenytoin is equally efficacious compared to phenytoin but has fewer adverse effects, such as hypotension and heart block.
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A man comes to the ED after a continuous seizure for teh last 30 minutes. There has been no response to repeated injections of benzodiazepines (lorazepan, diazepam).
What would you do if this treatment does not work? |
If fosphenytoin does not work, then treatment is with phenobarbital. For the rare patient that does not respond to benzodiazepine, fosphenytoin, or phenobarbital, then general anesthesia with midazolam, propofol, or pentobarbital should be used. Neuromuscular blocking agents, such as vecuronium or succinylcholine, will stop the muscle contractions but will NOT stop the seizure in the central nervous system.
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A 42 yo man comes to the emergency department with the sudden onset of a very severe headache. There is neck stiffness as well. His blood pressure is 170/120. The CT scan shows a subarachnoid hemorrhage.
What is the best initial therapy? |
Subarachnoid hemorrhage is initially managed by controlling the BP to a systolic <160 to prevent further bleeding.
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A 42 yo man comes to the emergency department with the sudden onset of a very severe headache. There is neck stiffness as well. His blood pressure is 170/120. The CT scan shows a subarachnoid hemorrhage.
What is the best drug therapy? |
Nimodipine is a calcium channel blocker that is used to prevent subsequent vasospasm. Nimodipine is the standard of care after SAH to prevent stroke.
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A 42 yo man comes to the emergency department with the sudden onset of a very severe headache. There is neck stiffness as well. His blood pressure is 170/120. The CT scan shows a subarachnoid hemorrhage.
What is the most important diagnostic test to guide therapy? |
A cerebral angiogram is performed to guide operative therapy. Surgical clipping is performed to prevent rebleeding. Embolization of the site of the aneurysm is useful and can be done by a catheter; a platinum wire is placed into the site of the bleeding. Embolization can be as effective as a surgically placed clip and does not require craniotomy.
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A man is evaluated for diplopia and weakness. His anti-cholinesterase antibodies are positive. Single-fiber electromyography shows a diminishing amplitude with repetitive stimulation.
What is the best initial therapy? |
Oral anticholinesterase medications, such as pyridostigmine or neostigmine, are the best initial therapy for myasthenia gravis.
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A man is evaluated for diplopia and weakness. His anti-cholinesterase antibodies are positive. Single-fiber electromyography shows a diminishing amplitude with repetitive stimulation.
How does this therapy work? |
Pyridostigmine or Neostigmine increase the amount of acetylcholine at the neuromuscular junction by inhibiting its metabolism.
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A man is evaluated for diplopia and weakness. His anti-cholinesterase antibodies are positive. Single-fiber electromyography shows a diminishing amplitude with repetitive stimulation.
What are its most common adverse effects? |
OD of pyridostigmine can lead to diarrhea, cramping, salivation, and bronchorrhea.
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A man is evaluated for diplopia and weakness. His anti-cholinesterase antibodies are positive. Single-fiber electromyography shows a diminishing amplitude with repetitive stimulation.
What would you do if the best therapy does not work? |
If pyridostigmine is ineffective, a patient should have the thymus removed. Thymectomy is generally only effective for those under 60 years old. Older patients, or those in whom thymectomy is ineffective, can be treatment with prednisone, then switched to azathioprine, mycophenolate, or cyclosporine. These medications are steroid sparing. Acute, severe myasthenic crisis is treated with plasmapheresis or IVIG.
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