Neurology Pharmacology

Front 1

avonex

Back 1

beta-INF 1a: 30 mg IM q wk,

delay progression

Front 2

Rebif

Back 2

high-dose Beta IFN 1a: 22 or 44 microg SC QOD -

dose related benefit, much higher rate of neutralizing antibodies

Front 3

Betaseron

Back 3

Beta-IFN 1b
8 MIU IU SC QOD

may delay progression in active relapsing-remitting or secondary progressive MS

Front 4

glatiramer

Back 4

copaxone

fragments of myelin basic protein 20 micro gm SC qd

Front 5

mitoxantrone

Back 5

approves for active relapsing-remitting secondary progressive MS

- inhibits topoisomerase II; interferes with RNA and crosslinks breaks DNA proliferating and nonproliferating cells

has a lifetime dose limit

Front 6

cyclophosphamide

Back 6

cytoxan

controversial

for aggressive progressive MS

Front 7

MS attack

Back 7

high dose : methylprenisolone IV 1000mg x 3 days, with/without taper

Front 8

fatigue from MS treat with?

Back 8

modafinil 100-2000 mg in AM and at noon

pharmacology of modafinil is?

Hint 8

to increase the levels of various monoamines,
- dopamine in the striatum and nucleus accumbens
- noradrenaline in the hypothalamus and ventrolateral preoptic nucleus,
- serotonin in the amygdala and frontal cortex

Front 9

treatment for transverse myelitits

Back 9

1 g methylprednisolone IV or 100 mg dexamethasone IV for at least 3 days

consider IVIg

Front 10

McDonald Criteria for MS Dx (5)

Back 10

1. 2+ attacks and 2+lessions

2. 2+ attacks and 1 lesion, with dissemination in space by MRI or 2+ MRI lesions plus CSF or 2nd clinical attack in different site

3. 1attack, 2+ lesions, dissemination in time by MRI, or 2nd clinical attack

4. 1 attack and 1 lesion disseminated in space by MRI or 2+ MRI lesions plus CSF

5. Insidious neurological progression - one year of progression and 2 of the following 3: MRI lesions or 4 - T2 lesions with VEP, spinal cord 2 lesions; + CSF

Front 11

Treatment for GBS includes?

Back 11

plasmapharesis - ANS instability is a relative contraindication

IVIG - equally effective

Front 12

treatment of CIDP or multifocal motor neuropathy includes?

Back 12

long term IVIG, plasma exchange and steroids DO NOT WORK!

Front 13

What are two possible treatments for chronic aggitation-delerium?

Back 13

respiridone - less sedating

quetiapine - less risk of movement disorder

Front 14

What treatment can you give Lewy Body disease?

Back 14

can try low-dose Levodopa or a dopamine agonists

in combination with : an atypical neuroleptic - quetiapine

Front 15

What is the treatment for acute cluster headaches?

Back 15

Ergot
100% O2


What is the treatment for prevention of cluster headaches?

Hint 15

Calcium channel blockers or lithium

Front 16

What mechanism of action are the triptans?

Back 16

5-HT1 serotonin receptor agonists

What is a major contraindication of taking triptans?

Hint 16

if you have taken an Ergot withint the previous 24 hours, also CAD could be a contraindication

Front 17

How do we administer Dihydroergotamine?

Back 17

put patient on cardiac monitor for first DHE dose,

- give metoclopramide 10 mg IV 10 min beforehand

- then give 1 mg DHE

-repeat in 1 hour prn, then q6h prn if it works

Front 18

When do we start prophylactically treating migraines?

Back 18

if the patient is having them 3+ /month

Front 19

What is the treatment for prevention of migraine's?

Back 19

Amitriptyline - proven efficacy

- propranolol - start 10-20 bid

- 5-HT antagonists - methysergide (need test dose, danger of retroperitoneal fibrosis)

- CCB - verapamil (cardiac selective, but will minimally vasodilate)

Front 20

What drugs do we use to treat a brain abscess assumingly from ear or from an unknown source?

Back 20

Ceftriaxone 2g IV q12h
and
Metronidazole 500 mg IV q6h

Front 21

What drugs do we use to treat a brain abscess in a post head truama or surgery patient?

Back 21

Staph aureus is more highly suspected

treat with vancomycin 1 g IV q 12 hours
and
ceftrazidime 2 g IV q8h or cefepime 2g IV q 12 hour (both have pseudomonas coverage, weaker Gm+, but Van will cover gm +)

Front 22

What is the treatment for neuropathy associated with lyme disease?

Back 22

doxycycline 100mg BID x 21-28 d
or
amoxicillin 500 mg TID x 21-28 days

What is the treatment for Lyme disease meningitis?

Hint 22

Ceftriaxone 2 g IV q12 hours x 2-6 weeks

Front 23

Patient presents with viral like symptoms, then rapidly progresses to having abnormal behavior, amnesia, seizures, hemiplegia, and could have altered level of consciousness, suspected diagnosis?

Back 23

Herpes simplex encephalitis

Front 24

What is a good drug for vasospasm control?

Back 24

Nimodipine 60 mg q4h PO after 30mg q2h to a total dose of 180mg/d as tolerated.

Front 25

What is Milrinone?

Back 25

Milrinone is a phosphodiesterase-3 inhibitor,

This drug inhibits the action of phosphodiesterase-3 and thus prevents degradation of cAMP. With increase cAMP levels there is an increase activation of PKA.

Phosphorylation of calcium channels permits an increase in calcium influx into the cell.

Front 26

Name the receptors activated and effects of this activation for each medication:

1. Dopamine:
2. Norepinephrine
3. Phenylephrine
4. Isoproterenol
5. Epinephrine

Back 26

1. Dopamine: D1, D2 and then non-selective mostly, mildly increased renal perfusion, but overall very non-selective

2. Norepinephrine: alpha slightly more than beta,

3. Phenylephrine: alpha1 only

4. Isoproterenol: beta only,

5. Epinephrine: non-selective

Front 27

What is the mannitol dosing for elevated ICP?

Back 27

1g/kg (usually 50-100g) IV bolus

then 25 mg q6h for:
- osm < 310
- Serum Na < 160
- osmolal gap < 10

Front 28

How do we reverse anticoagulation if patient was on coumadin?

Back 28

give 2-4 units of FFP and IV Vit K 10mg x 1, until INR < 1.3

Front 29

If patient is on coumadin (warfarin) and asprin, how do we reverse the anticoagulation?

Back 29

for coumadin: 2-4 units of FFP and IV Vit K 10mg x 1

For asprin: give 6 units of platelets

Front 30

What do we treat a patient with who has poor CSF resorption?

Back 30

acetazolamide - decreases CSF production

osmolar agent, and/or shunt

Front 31

What are the antihypertensives we should avoid when we have a high ICP?

Back 31

nitroprusside
nitroglycerine
hydralazine
Ca channel blockers other than Nicardipine

These all raise ICP via vasodilation and therefore decrease cerebral blood flow

Front 32

What chelating agent can we use to treat arsenic, lead, or mecury?

Back 32

penicillamine 250 mg PO qid

Front 33

What is the purpose of benzatropine?

Back 33

Benzatropine is an anticholinergic drug used in patients to reduce the side effects of antipsychotic treatment, such as pseudoparkinsonism and dystonia.

Front 34

How does Haloperidol work in treatment of choreoathetosis?

Back 34

Haloperidol is a typical neuroleptic that has D2 receptor antagonism, this will block the excess DA actions, and treat symptoms

Front 35

What is the function of entacapone?

Back 35

Entacapone is a COMT inhibitor, which COMT (catechol-O-methyl transferase) is an enzyme used to degrade dopamine, this will decrease level of degradation of DA and is used to treat parkinson's disease

Front 36

What is the function of pramipexole?

Back 36

This is a dopamine agonist, more sedative and causes hallucinations but longer half-life and less link to dyskinesias than levodopa

Front 37

What do drugs like selegiline and rasagiline do?

Back 37

They are both Monamine oxidase B irreversible inhibitors: which MAOB prefers to metabolize Dopamine (DA) specifically, whereas MAO-A: prefers to metabolize norepinephrine (NE), serotonin (5-HT), and Dopamine (DA) and are used in the treatment of depression

Front 38

How does amantadine work?

Back 38

a weak antagonist of the NMDA type glutamate receptor, increases dopamine release and blocks dopamine reuptake

Front 39

How does trihexyphenidyl (artane) work?

Back 39

It binds to the M1 muscarinic receptor[1] and possibly the dopamine receptor

The exact mechanism of action in parkinsonian syndromes is not precisely understood, but it is known that trihexyphenidyl blocks efferent impulses in parasympathetically innervated structures like smooth muscles (spasmolytic activity), salivary glands, and eyes (mydriasis)

Front 40

What is promethazine?

Back 40

aka phenegran
- a first-generation antihistamine, drug has anti-motion sickness, antiemetic, and anticholinergic effects, as well as a strong sedative effect

Front 41

What is ondansetron?

Back 41

aka Zofran:
- is a serotonin 5-HT3 receptor antagonist used mainly as an antiemetic (to treat nausea and vomiting), often following chemotherapy

Front 42

How does clonidine work?

Back 42

Clonidine treats high blood pressure by stimulating α2 receptors in the brain, which decreases cardiac output and peripheral vascular resistance, lowering blood pressure.

It has specificity towards the presynaptic α2 receptors in the vasomotor center in the brainstem. This binding decreases presynaptic calcium levels, and inhibits the release of norepinephrine (NE). The net effect is a decrease in sympathetic tone.

Front 43

What is riluzole?

Back 43

Riluzole preferentially blocks TTX-sensitive sodium channels, which are associated with damaged neurons.[1] This reduces influx of calcium ions and indirectly prevents stimulation of glutamate receptors.

Its used to treat ALS, delays the onset of ventilator-dependence or tracheostomy in selected patients and may increase survival by approximately 3–5 months

Front 44

What is the effects of botulism?

Back 44

toxin blocks acetylcholine ACh release from NMJ.

Front 45

How does edrophonium work?

Back 45

is a short-acting cholinesterase inhibitor, used in the tensilon test, should alleviate symptoms in myasthenia gravis patient

Front 46

How does prostigmine (neostigmine) work ?

Back 46

as a reversible acetylcholinesterase inhibitor.

Front 47

How does ipratropium bromide work?

Back 47

an anticholinergic drug used for the treatment of chronic obstructive pulmonary disease and acute asthma. It blocks the muscarinic acetylcholine receptors in the smooth muscles of the bronchi in the lungs, opening the bronchi

Front 48

What medication do we treat active seizures with, or status epilepticus?

Back 48

diazepam

Front 49

What is the treatment of choice for patient with partial or secondary generalized seizures?

Back 49

Levetiracetam (keppra), carbamazepine (tegretol) are first line more than valproate

Front 50

What is the treatment of choice for a patient that suffers from primary generalized seizures?

Back 50

valproate and carbamazepine (tegretol) are first line

*avoid ethosuximide, can make seizures worse

Front 51

What is the treatment of choice for patient with absence (petit mal) seizures?

Back 51

ethosuximide or valproate,


*avoid: phenytoin can make seizures worse

Front 52

What is the treatment of choice for myoclonic seizures?

Back 52

valproic acid or clonazepam

*avoid: phenytoin or carbamazepine

Front 53

What is a good first line treatment for seizures in a young woman?

Back 53

lamotrigine (lamictal) or carbamazepine (tegretol)

*avoid: phenytoin - teratogenic

Front 54

What are the first line treatments for patients with liver disease?

Back 54

levetiracetam (keppra) and lamotrigine (lamictal)

Front 55

Zolpidem (ambien) - mechanism of action and good time to use it:

Back 55

- nonbenzodiazepine GABA receptor drug, very good for anxiety and sleep disorder in the elderly, very little addiction associated and short half-life

Front 56

What is Ramelteon and how does it work?

Back 56

Ramelteon is in a class of medications called melatonin receptor agonists.

- Specifically used for patients who have sleep onset insomnia, effects last for roughly 8 hours

Front 57

How does Trazadone work and when do we use it?

Back 57

Trazadone is an inhibitor of: adrenergic receptors, histamine receptors, and some serotonin receptors, but is a partial agonists of 5-HT1A.

Its overall affects are mild anti-depression and anti-anxiety, with additional effects of a sleep aid due to the adrenergic inhibition.

Used to treat insomnia with/without depression/anxiety

Front 58

How does doxepin work and what do we use it for?

Back 58

Doxepin inhibits the reuptake of serotonin and norepinephrine. Doxepin also has antagonistic effects at a variety of receptors:
Extremely strong: H1, H2
Strong: 5-HT2, α1-adrenergic, mACh
Moderate: 5-HT1, local anesthetic action.


Doxepin is used to treat depression, anxiety disorders, insomnia and as a second line treatment of chronic idiopathic urticaria.[

Front 59

How does methylphenidate work and what do we use it for?

Back 59

increases the levels of dopamine and norepinephrine in the brain through reuptake inhibition of the respective monoamine transporters.


Methylphenidate (Ritalin) is a psychostimulant drug approved for treatment of ADHD or attention-deficit hyperactivity disorder,

Front 60

How does modafinil work and what do we use it for?

Back 60

The exact mechanism of action of Modafinil is unclear, although numerous studies have shown it to increase the levels of various monoamines, namely; dopamine in the striatum and nucleus accumbens, noradrenaline in the hypothalamus and ventrolateral preoptic nucleus, and serotonin in the amygdala and frontal cortex.

treatment of narcolepsy, shift work sleep disorder, and excessive daytime sleepiness associated with obstructive sleep apnea. Also has been shown to help in ADHD and concentration.

Front 61

What do we use to treat cataplexy?

Back 61

TCAs: imipramine 25 mg TID

Front 62

What do alpha-receptor agonists control?

Back 62

vasoconstriction
intestinal relaxation and sphincter constriction
increased heart contractile force
arrhythmias
dilated pupils

What is a selective alpha-agonists and what is an alpha-antagonists?

Hint 62

Alpha-agonist: phenyephrine

Alpha-antagonists: prazosin

Front 63

What do Beta-1 receptor agonists do and what do Beta-2 receptor agonists do?

Back 63

Beta-1: cardioselective - increased heart contractile force, increased heart rate, AV conduction, renin secretion,

Beta-2 : vasodilation, bronchodilation, intestinal relaxation

Name some beta-receptor agonists and a general beta-receptor antagonist

Hint 63

Beta-receptor agonists: isoproterenol

with beta-1 agonists: dobutamine

with beta-2 agonists: albuterol and terbutaline

beta- general antagonists: propranolol
beta-1 selective antagonists: metoprolol

Front 64

What receptor activity do Norepinephrine and epinephrine have?

Back 64

NE and Epi have equal binding to alpha receptors, and both have binding activity to both beta receptors, but Epi has an increased affinity to binding to beta-2 receptors than NE

What does this mean when choosing a pressor?

Hint 64

If we need both beta and alpha affects, then one of these two drugs should be chosen, if the patient has any COPD or asthmatic component of their decomposition, then Epi would be first line.

Front 65

What receptors does DA activate and in what concentration dependency?

Back 65

At very low dosee: 0.5-2 micro/kg/min selectively only activates D1, D2 receptors

At mid-range dosese 2-10 micro/kg/min will activate both Beta receptors and both Dopamine receptors

At high doese >10mico/kg/min will activate both alpha receptors, both beta, and both dopamine receptors

Front 66

What do alpha-2 receptor agonists do?

Back 66

cause platalet aggregation, lower insulin secretion, lower NE and acetylcholine release (can be used to increased cardiac output while vasodilating mildly),

What is an example of a alpha-2 agonists and an alpha-2 antagonist?

Hint 66

Alpha-2 agonist: clonidine, dexmedetomide

alpha-2 antagonists: yohimbine

Front 67

Which out of the adrenergic receptors, alpha, beta, or dopamine, has the greatest effect on the heart?

Back 67

Beta-1 receptors: AV node, contractile forces, heart rate

Front 68

What are the longest acting opiates?

Back 68

MS contin,
methadone
levorhanol
fentanyl patch

Front 69

What is the side-effect profile of a patient who is going through withdrawal from opiod use?

Back 69

muscle aches, lacrimation or rhinorrhea, pupillary dilation, sweating, diarrhea, yawning, fever, insomnia

Front 70

If prescribing an opiod, what should you also prescribe at the same time?

Back 70

2 senna tabs TID
metoclopramide 10 mg TID (only in patient with low risk for movement disorder)
colace 100 mg TID
lactulose or poylethylene glycol (miralax)

Ileus: oral narcan give 2-3 amp PO or as enema q4hours until bowel movement

Front 71

Name the trade name associated with each Opiod drug listed below:
1. Meperidine
2. Hydromorphone

Back 71

1. Meperidine - Demerol
2. Hydromorphone - Dilaudid

Front 72

What are the neurologic side effects of each of the following drugs:
1. acyclovir
2. Aminoglycodie
3. Amphotericin B
4. HIV drugs
5. Isoniazid
6. Metronidazole
7. Penicillin derivatives
8. Tetracyclines
9. Vancomycin
10. Zidovudine

Back 72

1. Acyclovir: encephalopathy is associated with renal failure, methotrexate, or interferon
2. Amingolycosides: vestibular and ototoxicity, neuromuscular blockade especially in myasthenia
3. Amphotericin B: rare headache, tremor, confusion, akindetic mutism
4. HIV: distal symmetrical polyneuropathy
5. Isoniazide: seizures, altered mental status, optic neuritis
6. metronidazole: distal exonopathy, psychosis, hallucinations
7. Penicillin derivatves: rare myoclonus, asterixis, and coma
8. Tetracyclines: rare pseudotumor cerebri in infants
9. Vancomycin: ototoxicity
10. Zidoviudine: HA, insomina, sometimes confusion, seizures, myopathy

Front 73

What is the goal INR for A-fib?

Back 73

2-3

Front 74

How do we monitor coumadin (warfarin), heparin, and enoxaparin (lovenox) respectively?

Back 74

warfarin (coumadin) - PT/INR

Heparin: PTT, therapeutic range is 60-80

Enoxaparin (lovenox): Factor Xa

Front 75

What type of medicine can we use for anticoagulation if a patient has a history of heparin induced thrombocytopenia?

Back 75

heparinoids: danaparoid, fondaparinux (arixtara), danaparoid (orgaran) these are synthetic heparin-like polysaccharides, they bind antihrombin III and thus inhibit factor Xa

Direct THrombin inhibitors: lepirudin, hirudin, argatroban, ximelagatran *these are hard to monitor and have no specific antidotes

Front 76

How do we reverse Warfarin (coumadin)?

Back 76

Vit K 1mg IV/SQ to lower PT a little, 10mg qd x 3 d to normalize, but makes anticoagulation hard for the next week

If active bleding, consider fresh frozen plasma or DDAVP to bolost platelets

Front 77

How do we reverse heparin?

Back 77

protamine 10-50 mg IV over 5 mins,

1 mg reverses approximately 100 U of heparin

Again if active bleeding can give FF Plasma and DDAVP to boost plateletes

Front 78

What do we need to check before we start somenoe on Carbamazepine?

Back 78

CBC - can cause leukopenia,

LFTs - can cause hepatitis

BMP - can cause low Na

Iron - do not start if iron > 15% micrograms, because it autoinduces its metabolism

What additional side effects are of concern with carbamazepine?

Hint 78

RASH!!

HA, nausea, ataxia. and need to increase oral contraceptive dose

Front 79

What is the major side effect to be aware of with lamotrigine (lamictal)?

Back 79

rash

What is the biggest side efefct to be aware of with use of levetiracetam (keppra)?

Hint 79

rash

Front 80

What are the contraindications for phenytoin use?

Back 80

secondary or complete AV block
bradycardia
hypotension
low ejection fraction
pregnancy

What are the side effects of phenytoin?

Hint 80

sedation, nystagmus, ataxia, transient dystonias, ophthalmoplegia, and rash

chronic: coarse features, gingival hyperplasia, ataxia, cerebellar atrophy

Front 81

What is the therapeutic dose for phenytoin?

Back 81

10-20 microgram/ ML or free level of 1-2 microgram/mL

Front 82

If given the measued dilantin level in the blood how do we calculate the free phenytoin level?

Back 82

free level = measured level / [ (0.2 x albumin) + 0.1]

* this also works if a person has a low albumin and the free might be different based on more free relative to bound

How do we calculate the free phenytoin level in a person with renal failure (CrCl < 20)?

Hint 82

adjusted level = measured level / [ (0.1 x albumin) + 0.1]

Front 83

What are the pharmacokinectics of phenytoin near its theraputic level in the body?

Back 83

kinetics change from first order to saturation near therapeutic dose

What does this mean when we are dosing a level initially < 8 vs a level > 8 but subtherapeutic because its still less than 10-20?

Hint 83

<8 : can increase dose by 100 mg qd

>8 : can increase the dose by no more than 50 mg

Front 84

What are the side effects of Valproate (Depakote)?

Back 84

liver toxicity (check LFTs)
Nausea
weight gain
thin hair
teratogenic
polycystic ovarian syndrome
pancreatitis
hepatitis

Front 85

How does mirtazapine (remeron) work?

Back 85

Mirtazapine (remeron) work as an antagonists at adrenergic, seretonin, histamine, and muscarinic receptors

- Good to treat insomnia, tremor, anxiety, and cachexia

Front 86

How do selegiline and rasagiline work?

Back 86

MAO-B inhibitors:
- MAO-B metabolizes dopamine and phenylethylamine. Selegiline exhibits little therapeutic benefit when used independently, but enhances and prolongs the anti-Parkinson effects of levodopa.

Rasagiline - also an MAO-B inhibitor

Front 87

What does an MAO-A inhibitor do?

Back 87

It preferentially deaminates norepinephrine (noradrenaline), epinephrine (adrenaline), serotonin, and dopamine (dopamine is equally deaminated by MAO-A and MAO-B).


It is inhibited by clorgiline and befloxatone

Front 88

How do tricyclic antidepressants work?

Back 88

antagonists of adrenergic, cholinergic, and histamine.

before starting a person on TCA what should we check?

Hint 88

EKG: this is a Na+ channel blocker and can prolong AV node depolarization --> prolonged PR, QRS, and QT

Front 89

What are the metabolic profiles of the following?

1. alprazolam (Xanax(
2. clonazepam (klonopin)
3. Chlordiazepoxide (librium)
4. Diazepam (valium)
5. Lorazepam (ativan)
6. Oxazepam (serax)

Back 89

1. Alprazolam (xanax) - fast metabolism
2. clonazepam (klonopin) - slow metabolism
3. chlordizepoxide (librium) - slow metabolism
4. diazepam (valium) - slow
5. lorazepam (ativan) - fast metabolism
6. oxazepam (serax) - fast metabolism

Front 90

Calcium channel blockers: Diltiazem, verapamil, and nifedipine.

List with regards to blood pressure effects from most lower to least

List with regards to cardiac affects from most nodal blockade to least.

Back 90

Lowers blood pressure: nifedipine > diltiazem > verapamil

Cardiac: Verapamil > diltiazem >>>> nifedipine

Front 91

What are the side effects of digoxin toxicity?

Back 91

vomiting, diarrhea, diplopia, yellow-haloed vision, confusion, long PR interval, heart block, junctional tachy, V Tach, and V fib

Front 92

How does Nacardipine work?

Back 92

Nacardipine - mechanism of action and clinical effects closely resemble those of nifedipine and the other dihydropyridines (amlodipine, felodipine), except that nicardipine is more selective for cerebral and coronary blood vessels.