Nur 235 Pharm Exam 2 Part 2

Front 1

6th leading cause of death among adults

Back 1

Alzheimer's

Front 2

4 characteristic s/sx of Alzheimer's

Back 2

-progressive memory loss

-impaired thinking

-neuropsychiatric problems

-inability perform ADL

Front 3

How many americans have alzheimer's?

Back 3

4.5 million, or 5 to 10% of populations

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7 aspects of the pathophysiology of alzheimer's disease

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-degenerative

-vascular

-infectious

-metabolic

-psychiatric

-development of senile plaques

-development of neurofibrillary tangles

Front 5

Progression of neuronal degeneration in Alzheimer's starts at what part of the brain?

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Hippocampus (memory)

Front 6

What part of the brain is effected in alzheimer's that controls speech, perception, reasoning, and executive thinking?

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Cerebral cortex- decreased cerebral volume

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What are advancing sx of Alzheimer's with advanced cortical degeneration?

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-complete loss of speech

-loss of bladder

-loss of bowel

-complete inability for self care

Front 8

What neurotransmitter declines in advanced Alzheimer's?

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Acetylcholine levels are 90% below normal

Front 9

This neurotransmitter is critical for forming memories.

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Acetylcholine

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spherical bodies composed of a central core of _________ (a protein fragment) surrounded by neuron remnants

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beta-amyloid

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neuritic plaque in Alzheimer's

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beta-amyloid

Front 12

when does beta-amyloid accumulation start to occur?

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perhaps 10 to 20 years before first symptoms of AD appear.

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What is tau & what does it do in healthy person? What does it do in alzheimer's?

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Tau is a protein that normally forms cross bridges between microtubules. In alzheimer's tau twists into paired helical filaments that form tangles.

Front 14

what is the major risk factor of alzheimer's?

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age. 90% of patients age of onset is 65 years or older.

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What are the risk factors of alzheimer's?

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-advanced age over 65

-family hx of AD

-female?

-nicotine?

-head injury?

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4 mild sx of alzheimer's

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-confusion and memory loss

-disorientation in familiar surroundings

-problems with routine tasks

-changes in personality & judgement

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6 moderate sx of alzheimer's

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-difficulty with ADL

-anxiety, agitation, paranoia

-sleep disturbances

-wandering

-sundowning

-difficulty recognizing family & friends

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4 severe sx of alzheimer's

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-loss of speech

-loss of appetite

-loss of bladder & bowels

-total dependance on caregiver

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how to diagnose alzheimer's

-definitive & 2 ballpark while alive.

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-autopsy

-mini mental exam

-clock drawing

Front 20

2 goals of tx for Alzheimer's

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-improve symptoms

-reverse cognitive decline

Front 21

Four drugs for alzheimer's treatment

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1. DONEPIZIL- cholinesterase inhibitor

2. Galantine- cholinesterase inhibitor

3. Rivastigmine- cholinesterase inhibitor

4. Nemantine- blocks neuronal receptors for N-methyl-D-aspartate (MNDA)

Front 22

how do cholinesterase inhibitors work?

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They prevent the breakdown of AcH by acetylcholinesterase and increase the availability of AcH at cholinergic synapses.

Front 23

what are general side effects of the cholinesterase inhibitors?

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(TYPICAL CHOLINERGIC SIDE EFFECTS)

-GI symptoms-nausea, vomiting, dyspepsia, diarrhea

-Headache

-dizziness

-bronchoconstriction

-CV

Front 24

how does cholinesterase inhibitor dosing generally work?

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-highest does produce best result, but also produce biggest side effects.

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Only cholinesterase inhibitor used for MILD, MODERATE, & SEVERE Alzheimer's disease.

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Donepezil (Aricept)

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Cholinesterase inhibitor drug interactions:

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-Benedryl/dihydremine

-Tricyclic antidepressants

-Antipsychotics

Front 27

Must be careful when treating Alzheimer's Patients with cholinesterase inhibitors when they have these 2 diseases

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-asthma

-COPD

Front 28

Donepezil (Aricept) is more selective for which form of AChE

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more selective for AChE found in the brain than for AChE found in periphery

Front 29

What are pharmakinetics for Donepezil?

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-PO

-metabolized by hepatic cytochrome P450 enzymes

-elimination mainly in urine (some in bile)

Front 30

what is the half life of Donepezil (Aricept)

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prolonged half life of 60 hours

Front 31

dosing for Donepezil (Aricept)

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-carefully titrated doses

-standard tablets 5-10 mg or 23 mg

-ODT oral disintegrating tablets 5 and 10 mg

Front 32

When & how to take Doneprizil (Aricept)

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Late in evening, with or without food

Front 33

What is the new class of drugs for Alzheimer's

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NMDA receptor antagonists

Front 34

What drug is in the class of NMDA receptor antagonists?

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Memantine (Named, Named XR, Ebixa)

Front 35

What is the mechanism of action for NMDA receptor agonists

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modulates the effects of glutamate (major excitatory transmitter in CNS) at the NMDA receptors

Front 36

What is the major excitatory transmitter of CNS that Memantine (Namenda) modulates?

Back 36

Glutamate

Front 37

Which alzheimer's patients is Memantine (Namenda) indicated for?

Back 37

-moderate and severe NOT MILD.

Front 38

How does Memantine help in Alzheimer's

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-it blocks calcium influx when extracellular glutamate is low, but permits calcium influx when extracellular glutamate is high.

Front 39

What drug may be able to slow or even reverse decline in function?

Back 39

Memantine

Front 40

What are the pharmacokinetics for Memantine?

Back 40

PO

-well absorbed in presence and absence of food

-plasma levels eat in 3 to 7 hrs

-undergoes little metabolism

-excreted largely unchanged in urine

-long half life 60 to 80 hours

-clearance reduced with renal impairment

Front 41

Side effects of Memantine (Named)

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(Well tolerated)

-dizzyness

-headache

-confusion

-constipation

Front 42

how many people in US have epilepsy?

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2.3 million

Front 43

what percentage of epilepsy patients are seizure free with drugs?

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60 -70%

Front 44

difference between seizures and epilepsy

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epilepsy- chronic condition

seizure- isolated event

Front 45

How are seizures initiated?

Back 45

by high frequency discharge from a group of hyper excitable neurons called a focus

Front 46

What is a focus in terms of seizures?

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a group of hyper excitable neurons that initiate a high frequency discharge. May result from congenital defects, hypoxia, head trauma or cancer.

Front 47

2 broad categories of seizures

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1. Partial (focal ) seizures

2. Generalized Seizures

Front 48

True or false: As a rule, partial seizures and generalized seizures are treated with different drugs

Back 48

true

Front 49

Duration of simple partial seizures

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20 to 60 seconds

Front 50

This distinguishes a simple partial seizure from a complex partial seizure.

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There is no loss of consciousness.

Front 51

These seizures are discrete, motor, sensory auditory, or visual. THERE IS NO LOSS OF CONSCIOUSNESS. Duration is 20 - 60 seconds.

Back 51

Simple partial seizure

Front 52

These seizures have impaired consciousness. The patient is motionless with fixed gaze. Duration is 45 to 90 seconds. Often followed by automatism- repetitive, purposeless movements.

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Complex Partial Seizures

Front 53

What is automatism?

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Repetetive, purposeless movements following a complex partial seizure.

Front 54

These partial seizures begin as simple or complex and evolve into tonic clonic activity. Duration of 1 -2 minutes. LOSS OF CONSCIOUSNESS.

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Secondarily Generalized Seizures.

Front 55

3 types of partial seizure

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-Simple Partial

-Complex Partial

-Secondarily Generalized Seizures

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Tonis

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Stiffen

Front 57

Clonis

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Thrashing

Front 58

What is postictal period

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period of CNS depression following generalized seizure in which patient is slow to respond, sleepy.

Front 59

2 categories of Generalized seizures

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-convulsive

-nonconvulsive

Front 60

6 major types of generalized seizures

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-Tonic Clonic (grand mal)

-Absence Seizures (petit mal)

-Atonic Seizures

-Myoclonic Seizures

-Status Epilepticus

-Febrile Seizures

Front 61

These seizures last 90 seconds or less and include periods of major convulsions and muscle rigidity, cause urination, and are followed by postictal state

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Tonic Clonic generalized seizures

Front 62

These seizures are characterized by a loss of consciousness for a brief time (10 to 30 seconds) and may involve mild, symmetric motor activity or no motor activity at all.

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Absence Seizures (petit mal)

Front 63

These seizures occur primarily in children and are characterized by sudden loss of muscle tone- head drops may occur, or patient may collapse.

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Atonic Seizures

Front 64

These seizures consist of sudden muscle contraction that lasts for just 1 second, may be limited to one limb or may involve entire body.

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Myoclonic seizures

Front 65

This is defined as a seizure that persists for 15 to 30 minutes or longer or as a series where patient does not regain consciousness

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Status Epilepticus

Front 66

These seizures occur with fever, often manifest as generalized tonic-clonic, and are common among children ages 6 mo to 5 years.

Back 66

Febrile Seizures

Front 67

5 basic mechanisms of AED's

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-suppression of sodium influx

-suppression of calcium influx

-promotion of potassium efflux

-blockade of receptors for glutamate

-potentiation of gamma-aminobutyric acid (GABA)

Front 68

These 4 AED's prevent seizures by reversibly binding to sodium channels while they are in the inactivated state, and thereby prolong channel inactivation.

Back 68

-Phentoin (Dilantin) (traditional)

-Carbamazepine (Tegretol) (traditional)

-Valproic Acid (Depakote) (Traditional)

-Lamotrigine (Lamictal) (newer)

Phil Collins Values Love

Front 69

these 2 drugs suppress calcium influx in axon terminals, blocking transmitter release.

Back 69

-Valproic Acid (Depakote)- traditional

-Ethosuximide (traditional)

Front 70

This drug suppresses both calcium influx and sodium influx

Back 70

Valproic Acid (Depakote) -traditional

Front 71

This is the only drug that promotes potassium efflux by acting on voltage gated potassium channels to facilitate potassium efflux.

Back 71

Ezogabine

Front 72

These 2 AEDs block the action of glutamate

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-Felbamate

-Topirimate (Topomax)- new

Front 73

-mate

Back 73

drugs that block the action of glutamate to prevent seizures

Front 74

2 receptors for Glutamate

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-NMDA

-AMPA

Front 75

5 drugs that decrease neuronal excitability by potentiating the activity of GABA.

Back 75

-Gabapentine (Neurontin)

-Benzodiazepines (Valium, diazepam)

-Barbituates

-Tiagabine

-Vigabatrin

Front 76

Inhibitory neurotransmitter widely distributed throughout brain

Back 76

GABA

Front 77

This was the first medication to suppress seizures w/out depressing the entire CNS

Back 77

Phenytoin (Dilantin)

Front 78

This AED suppresses high frequency neuronal discharge and is also used in bipolar disorder

Back 78

Carbamazepine (Tegretol)

Front 79

This AED is widely used for all major types of seizures, and also treats bipolar disorder and migraines

Back 79

Valproic Acid (Depakote)

Front 80

Phenytoin (Dilantin) mechanism for action

Back 80

at clinical concentrations phenytoin causes selective inhibition of sodium channels

Front 81

Pharmacokinetics of Phenytoin (Dilantin)

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-unusual pharmacokinetics

-PO/XR PO absorbtion varies substantially among patients

-liver has limited ability to metabolize

-

Front 82

Phenytoin (Dilantin) can be used to treat all major forms of epilepsy EXCEPT

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Absence Seizures

Front 83

This AED easily overwhelms the liver, leading to:

Back 83

Hepatotoxicity

Front 84

You will need to have plasma levels drawn to make sure this drug is within a safe Therapeutic range of 10 - 20 mcg/mL

Back 84

Phenytoin (Dilantin)

Front 85

Side effects of Phenytoin (Dilantin)

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-Nystagmus

-Gingival Hyperplasia

-Dermatologic

-Teratogenic

Front 86

What can you mix Phenytoin (Dilantin) with when giving as IV?

Back 86

ONLY NORMAL SALINE

Front 87

What rate can you give IV Phenytoin (Dilantin)?

Back 87

50mg/minute

Front 88

What category teratogenic drug is Phenytoin (Dilantin)

Back 88

Category D, give only if necessary and no other seizure drug will work.

Front 89

What AED drug must you cardiac monitor during entire infusion when giving as IV

Back 89

Phenytoin (Dilantin)

Front 90

What are four newer AED's

Back 90

-Oxcarbazepine (Trileptal)

-Lamotrigine (Lamictal)

-Gabapentin (Neurontin)

-Topiramate (Topamax)

(T LOG)

Front 91

This AED blockades the voltage-sensitive sodium channels and its most common adverse effect is dizziness (up to 49%)

Back 91

Oxcarbazepine (Trileptal)

Front 92

This AED was introduced in 1994. It can blockade sodium and calcium channels. It is also used in bipolar disorder

Back 92

Lamotrigine (Lamictal)

Front 93

This AED was introduced in 1993. Only FDA approved for seizures. However, widely used for neuralgia and neuropathic pain.

Back 93

Gabapentin (Neurontin)

Front 94

This AED was introduced in 1996 and has wide off label usage including: weight loss, bipolar disorder, cluster headaches and neuropathic pain.

Back 94

Topiramate (Topamax)

Front 95

How does the AED Levetiracetam (Keppra) work?

Back 95

It is chemically and pharmacologically different from all other AEDs and it is unknown how it its.

Front 96

This is the one AED that does not interact with other drugs

Back 96

Levetiracetam (Keppra)

Front 97

Levetiracetam (Keppra) side effects

Back 97

Drowsiness and lack of strength

Front 98

Pharmacokinetics of Levetiracetam (Keppra)

Back 98

-PO, oral solution, IV

-rapid and complete absorption w/ or w/out food

-metabolism is minimal, not mediated by liver cytochrome P450 enzymes

-excreted in urine, largely unchanged

Front 99

Monitor all seizure disorder patients for_____

Back 99

suicide risk