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179 Cards in this Set
- Front
- Back
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AD potential factors
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Inflammatory mediators
MAO-B Glutamate and other excitatory mediators NMDA decrease in concentraion of certain NTs |
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AD DDX
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D- Drugs and EtOH
E- Ears and Eyes M- Metabolic, endocrine, nutritional E- Emotional disorders N- Neurologic Disease T- Tumors and Trauma I- Infection A- Arteriosclerosis |
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Tacrine(Cognex) SE
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Cholinergic
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Donepezil(Aricept)SE
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Cholinergic
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Rivastigmine(Exelon) SE
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Cholinergic, especially GI
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Galantamine (Reminyl) SE
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Cholinergic, especially GI
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Drugs to Tx AD
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Tacrine(Cognex)
Donepezil(Aricept) Rivastigmine(Exelon) Glantamine(Reminyl) Vit E Memantine (Namenda) |
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Vitamin E
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Traps free radiacals and prevents further cell damage
Limits lipid peroxidation in cell cx reduces cell death with beta AP |
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Vitamin E
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Delayed institutionalization and delayed deline in ADLs
No significant change in cognition |
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Memantine (Namenda)
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NMDA receptor antagonist
Indicated in mod to severe AD |
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Antianxiety Meds
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Benzos
Buspirone SSRI and SNRI |
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Benzos
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GAD, PTSD, OCD
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Buspirone
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slow onset of action
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SSRI and SNRI
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LT therapy
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Benzos
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by the first dose you can see the reduction in aniety
really effective |
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Benzos
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anxiolytic
hypnotic muscle relaxant anticonvulsant amnesic actions |
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Benzos
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start low and go slow
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OCD
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SSRI
TCA- Clomipramine |
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Estimated adherance to LT therapy
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50%
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Insomnia RX
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OTC:
H1 aantagonists (diphenhydramine or doxylamine found in Unisom) L-tryptophan valerian melatonin EtOH |
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H1 antagonists SE
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anticholinergic
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MOA of Benzos and Benzo Receptor Agonists
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bind to GABA receptors in the brain
stimulating GABAergic transmission and hyperpolarization of neuronal mb |
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Effects of Benzos
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sedative
anxiolytic muscle relaxant anticonvulsant |
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Benzos
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Fluazepam (Dalmane)
Temazepam (Restoril) Esstazolam (ProSom) Triazolam (Halcion) |
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Non Benzos
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Zaleplon (Sonata)
Zolpidem (ambien) Eszopiclone (Lunesta) |
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AD potential factors
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Inflammatory mediators
MAO-B Glutamate and other excitatory mediators NMDA decrease in concentraion of certain NTs |
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AD DDX
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D- Drugs and EtOH
E- Ears and Eyes M- Metabolic, endocrine, nutritional E- Emotional disorders N- Neurologic Disease T- Tumors and Trauma I- Infection A- Arteriosclerosis |
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Tacrine(Cognex) SE
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Cholinergic
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Donepezil(Aricept)SE
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Cholinergic
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Rivastigmine(Exelon) SE
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Cholinergic, especially GI
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Galantamine (Reminyl) SE
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Cholinergic, especially GI
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Drugs to Tx AD
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Tacrine(Cognex)
Donepezil(Aricept) Rivastigmine(Exelon) Glantamine(Reminyl) Vit E Memantine (Namenda) |
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Vitamin E
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Traps free radiacals and prevents further cell damage
Limits lipid peroxidation in cell cx reduces cell death with beta AP |
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Vitamin E
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Delayed institutionalization and delayed deline in ADLs
No significant change in cognition |
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Memantine (Namenda)
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NMDA receptor antagonist
Indicated in mod to severe AD |
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Ambien CR
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slightly longer activity
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Rx meds used for sleep that shouldn't be
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Antidepressants (trazodone, mirtazapine, doxepine, amitriptyline)
Antipsychotics (Seroquel and Zyprexa) |
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Ramelteon (Rozerem)
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sleeper
melatonin-receptor agonist with activity at MT1 and MT2 not a controlled substance |
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How long do we treat for sleep...
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with the exception of the newest benzo receptor agonist (Eszopliclone)- all of these are indicated for Short term use
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Triazolam SE
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anterograde amnesiacognitive imparedment
motor incoordination dependance rebound insomnia |
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Sleep aid drug interactions
Triazolam eszopiclone zolpidem zaleplon |
use with caution if using drugs that inhibit CYP3A4
like ketoconazole nefazodone protease inhibitors fluvoxamine grapefruit |
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Half Lives
Fluazepam (Dalmane) Temazepam (Restoril) Esstazolam (ProSom) Triazolam (Halcion) |
Fluazepam (Dalmane)- long
Temazepam (Restoril)- slow Esstazolam (ProSom)- fast Triazolam (Halcion)- fast |
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Half Lives
Fluazepam (Dalmane) Temazepam (Restoril) Esstazolam (ProSom) Triazolam (Halcion) |
Fluazepam (Dalmane)- long
Temazepam (Restoril)- slow Esstazolam (ProSom)- fast Triazolam (Halcion)- fast |
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Half Lives
Zaleplon (Sonata) Zolpidem (ambien) Eszopiclone (Lunesta) |
Zaleplon (Sonata)- ultrashort
Zolpidem (ambien)- short Eszopiclone (Lunesta)- intermed |
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Azaspirodecanediones
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Busirone
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Buspirone
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lacks abuse potential
lacks cognative and respiratory depressant effects very little sedation |
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Benzo SE
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tiredness
memory deficits amnesia diff concentrating problems with balance and incoordination |
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Antidote to benzo OD
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Flumazenil IV
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Buspirone
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delayed onset of activity
doesn't work well on pts that have already taken benzos start buspirone before ending the benzos |
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SSRI, TCA and MAOi
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all considered int e tx of various anxiety d/o: esp OCD and Panic d/o
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Drug interactions with anxiolytics
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additive effect of sedation or psychomotor imparment with EtOH
Cimentidine increases levels of benzos high doses and clozapina= death BCP increase the levels |
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Hypnotics with short half lives
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lead to rebound insomnia
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Hypnotics with long half lives
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associated with sedative effects and cognitive or motor imparment the next day
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Barbituates
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amobarbital
pentobarbital secobarbital |
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Nonbarb/Nonbenzo
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ethchlorvynol
glutethimide methyprylon chloral hydrate- used in peds |
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L-tryptophan
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involved in non-REM sleep stages
fatalities: eosinophilia myalgia syndrome |
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Melatonin
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pineal gland and secreted during the nighttime adn ot environmental darkness
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CI to hypnotic use
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sleep apnea syndromes
excessive EtOH consumption pregnancy need for alert fxn during NL sleep period |
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Cautions for hypnotic use
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Pts who are elderly
have a h/o heavy snoring renal, hepatic or pulmonary dz other medications concomittantly suicidal tendencies hazardous occupations |
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Benzos
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Alprazolam (Xanax)
Chlordiazepoxise (Librium) Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan) Oxazepam (Serax) |
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Antidepressants Drug Therapy
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SSRI
SNRI TCA MAOI heterocyclics |
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SSRI are as effective as
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TCA
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SSRI
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Fluoxetine (Prozac)
Paroxetine (Paxil) Fluoxamine (Luvox) Citalopram (Celexa) Escitalopram (Levapro) Sertaline (Zoloft) |
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TCA
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Amitriptyline (Elavil or Endep)
Nortriptyline (Pamelor or Aventyl) Imipramine (Tofranil) Desipramine (Norpramin or Pertofrane) Doxepin (Sinequin) Trimipramide (Surmontil Amoxapine (Asendin) Protryptyline (Vivactil) |
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Meds that can precipitate depression
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methyldopa
resepine hydralazine clonidine propanolol amantadine levodopa barbs benzos EtOH amphetamine corticosteroids estrogen progesterone |
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SE of SSRI
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GI
N/V sedation/stimulation sexual dysfunction anorgasmia tremor insomnia nervousness |
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Proxetine (Paxil)
Fluoxetine (Prozac) Sertaline (Zoloft) |
GI upset with every increase in dosage
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Drugs that can casue seratonin syndrome
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MAOI
Meperidine St Johns Wart Cold Remedies Dextromethorphan Sympathomimetics Diet Pills |
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SE of TCA
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Anticholinergic
sedation dec cardiovascular dec seizure threshold orthosttic hypotn wt gain narrow angle glaucoma sinus tach dry mouth constipation blurred vision urinary retention and hesitency |
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4 major problems with TCAS
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slow onset
efficacy only 60-70% AE Lethargy |
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TCA dosing
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start low and titrate slow
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SNRI
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Cymbalta (duloxetine)
Effexor (venlafaxine) |
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SNRI
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same SE as SSRI
slight inc in diastolic BP |
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Remeron (mirtazapine)
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alt to SSRI
dec sex SE at inc doses |
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Nefazadone (Serzone)
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related to Trazodone
inhibits neuronal uptake of seratonin and NE and has anticholinergic activity |
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TCA drug interaction
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Cimentidine
MAOI |
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MAOI
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atypical depression
major depression antipanic agents |
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MAOI
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Tranylcypromine (Parnate)
Isocarbazide (Marplan) Phenelizine (Nardil) |
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MAOI Se
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orthostatic hypotn
mild anticholinergic delayed ejaculation |
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MAOI
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do not alter cardiac conduction
little effect on HR No tyramine containing food |
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MAOI Drug Interactions
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epinephrine
pseudoephrine stimulants amphetanmines Levodopa Meperidine |
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Heterocyclics
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Amoxapine
Trazodone Maprotiline Buproprion |
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Associated with seizures
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Maprotiline
Buproprion |
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Buproprion
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dopamine agonist effect
Zyban- antismoking form |
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Fluoxetine
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Prozac
Only agent approved for the tx of depression in children |
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Tetracyclic
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Maprotiline (Ludiomil)
Mirtazapine (Remeron) |
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Triazalopyridine
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Trazodone (Desyrel)
Nefazodone (Serzone) |
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Aminoketone
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Wellbutrin (Buproprion)
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SSNRI
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Effexor
Cymbalta |
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Ts for Bipoloar d/o
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Mood Stabilizers
Antipsychotics |
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Mood Stabilizers
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Mainstay of therapy
Lithium Valproate Lamotrigine Carbamazepine Oxcarbazepine |
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Aptypical Antipsychotics
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Olanzapine
queriapine |
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Tx of Bipolar d/o
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response may be seen in 7-10 days but you can add the use of an antipsychotic and get results in 3-5 days
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SE of Lithium
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death
stupor coma CV collapse seizure fine hand tremor GI upset (N, d, metal taste) T wave flattening widening of QRS DI wt gain hypothyroid leukocytosis teratogen mild polyuria polydipsia muscle weakness coarse tremor confusion sedation lethargy hyperreflexia slurred speech vertigo |
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Lithium
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oldest
low thereputic index Acute 0.7-1.2 Maint 0.6-1.0 laseline labs Na balance is important Multiple effects on NT similar to cation may take 10d-2 weeeks to lyse manic attack |
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Lithium drug interactions
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NSAIDS
ACEi diurectics |
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Meds that precipitate Mania
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all antidepressants- switch phenomenon
stimulatants cocaine amphetamines methylphenidate OTC drugs pseudephedrine phenylpropanolamide caffeine corticosteroids thyroid androgens |
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Valproate (Depakote)
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BPD
safer than Lithium 1st line agent LFTs tested Loading dose for acute pts check blood concentration after 4 days when using antidepressants tx for a shorter time |
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Lamictal (Lamotrigine)
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maint of BPD I
can be initial or primary therapy or adjuvant to valproate |
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Tegretol (Carbamezepine)
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BPD
Inc toxic to blood cells |
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Topramax (Topiramate)
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BPD
wt loss |
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Antipsychotics
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Olanzapine (Zyprexa)
1st line agent to tx acute BPD and maint should be used for least amount of time |
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Implanon
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implant
etonogestrel effective x 3yrs inhibits ovulation |
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Nuva Ring
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EE
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Mirena
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IUD
levonorestrel effective x5yrs high efficacy |
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OrthoEvra
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Pathc
norelgestromin (NGMN) plus EE |
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Estrogens
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EE
Mestranol |
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How estrogens work
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endometrial proliferation
effects on ovulation (FSH/) cycle control |
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Estrogen considerations
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dose is the primary concern
20-50mcg fixed doses incrimental estrogen doses most of the formulations have 35mcg or less rx the least ptoent formulation |
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Estrogen SE
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Nausea
Breast Tenderness h/a thromboembolic effect |
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Progestins
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Estranes
Gonanes |
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Estranes
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norethindrone
norethindrone acetate |
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Gonane
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Levonorestrel
norgestrel |
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How progestins work
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prevents ovulation (LH)
thickens cervial mucus endometrial transformation cycle control |
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Progestin considerations
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1st generations- noresthindrone
2nd gen- levonorgestrel 3rd gen- desogestrel and norgestimate |
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Progestin SE
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oily skin- acne may worsen or get better
h/a breast tenderness mood changes wt gain BTB hirsuitism |
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Hormaonal considerations
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mood changes
wt gain dec libido h/a androgenic SE |
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BCP interaction with Antibiotics
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PCN, tet, griseo
use backup protection |
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BCP interaction with Acitretin (soratane)
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use alternative or additional method
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BCP interaction with Anticonvulsants (phenytoin, carbanezepine, phenobarb, primidone)
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use alt method or use 2nd method
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BCP interaction with Ascorbic Acid
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Vit C
Avoid high doses of Vit C use dec doses of estrogen |
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BCP interaction with Rifamycin
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use nonhormonal contraception during therapy and for 1 cycle after tx ends or inc estrogen
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BCP interaction with Antivirals protease inhibitors
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inc estrogen
use 2nd method use alt method |
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BCP interaction with benzos
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may need to dec benzo dose if CNS sx occur
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BCP interaction with hypoglycemics
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pioglitazone (Actos)
rosiglitazone (Avandia) use alt methods use second method |
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COC as ECP uses
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1st dose less than 72 hrs
2nd dose 12 hrs after 1st repeat dose if vomitting within 3 hours meclizine/diphenhydramine may be admin to dec N/V no period in 2-3 weeks--> preg test |
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CI for COC as ECP
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thromboembolism
DVT CV dz or CAD estrogen dependant neoplasm |
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COC is a category???
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X-
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Progestin Pill ONLY
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levonorestrel
Ovrette Micronor 750 mcg within 72 hrs of unprotected sex repeat 12hrs later Failure rate <24hrs- 0.4% 24-72hrs- 2.7% N/V in 6% of users |
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Danazol
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sythetic androgen
2 regimines- 2-400 or 2-400 12 hrs apart |
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Danazol Considerations
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women with Ci to estrogen
women who can't tolerate SE of COC TERATOGEN--> MUST ABORT |
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Post Coital IUD Insertion
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Failure rate 0.1%
must be inserted by professional Cu T380A |
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Cu T380A MOA
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sperm: immobilizes, interferes with migration
Ovum: inc speed of transport Uterus: mechanical distention of endometrium |
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Cu T380A CI
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women at risk for STDs
Women allergic to Cu |
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Problems with Cu T380A
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insertion cna be difficult
bacteremia--> 13% abx prophylaxis |
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Benefits of Cu T380A
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women withCI to hormones
left in place x 10yrs insertion up to 5 days poist coital |
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High dose estrogen Administration
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"standard method"- 60s and 70s
increase SE but equal in effectiveness as Yuzpe bid x 5 days |
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Regimines of High dose estrogen
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2.5 EE
10 esterified or conjugated estrogens 5mg estrone 25 DES |
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Problems with High dose estrogen
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Estrogen CI
regimine is more complex SE no benefit of this over regular COC |
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Mifepristone
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EC
potent anti-progesterone pregnancy wasting "abortion pill" inc incidence of menstrual irregularities |
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Candidates for OCP
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menstrual hx
contraceptive hx PE exam premenopausal women risk for thromboembolism is increased after 35 in women who are obese and smoke over 40- better complicance |
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CI for OCP
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pregnancy
malignancy thromboembolism major surgery with expected prolonged immobilization smoker >35yo heavy smokers of any age CAD uncontrolled HTN undx vag bleeding |
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Causes of BTB
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missed pills
smoking infection formulation adjustment needed drug interactions- mechanism CYP3A4 induction with intestinal flora |
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Progestin only over 40
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lower efficacy
lower fertility do not alleviate menopausal sx |
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Risks of OCP
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N/V
abd cramping h./a migraines BTB bloating breast tenderness emotional lability acne rash edema thromboembolism MI storke sever HTN cholestatic jaundice depression hepatic adenoma breast CA |
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Benefits of OCP
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improves dysfxnal uterine bleeding
LT benefits protection against gyn Ca protection against colorectal Ca dec risk of RA dec PID related hospitalizations improvements in acne preservation in bone mass cycle regulation |
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EC effectiveness
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effectiveness is 75%
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Factors effecting efficacy of EC
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age
underlying dz state exposure to drug/toxins preious rad or surgery dec body fat |
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EC Options
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ECP
Progestin Only pills Danazol Postcoital IUD insertion high dose estrogen administration Mifepristone (RU 486) Early Identification and Abortion |
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Preven
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EC Kit approved by the FDA
YUZPE method estrogen (EE) plus progestin (norgestrel) 1st dose within 72 hrs of unprotected sex and then 2nd dose 12 hours later |
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COC as ECP
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inhibit ovulation
Estrogens: accelerate ovum transport degenerates CL change in secretions within the uterus Progestins: thick cervial mucus inhibit capacitation inhibit implantation slow ovum transport |
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Drug induced Parkinsons
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Antipsychotics
Metoclopramide (Reglan) |
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DOPA decarboxylase Inhibitors
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Carbidopa (Lodosyn)
Carb + Levo= Sinemet provides smoother, faster titration of levodopa dec SE of peripheral metabolism of Levodopa |
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Nonpharm tx for Parkinsons
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Exercise
PT OT Hollistic Palliative Surgical Individualized |
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Goal for Pharm therapy of Parkinsons
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inc availability of dopamine inthe brain
maintain existing levels of dopamine by preventing metabolism of DOPA inhibit the effects of increased Ach |
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Levodopa (Dopa, Larodopa)
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precurser to dopamine
crosses BBB converted in basal ganglia rapid absorption w/d: taper to avoid neuroleptic malignant syndrome |
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Levodopa/Carbidopa
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Sinemet
immediate release- food decreases absorption controlled release- food increases absorption |
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Levodopa/Carbidopa dosing
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individulaized dosing
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Levodopa/Carbidopa SE
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orthostatic hypotn
dizziness urinediscoloration |
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MAO-B Inhibitors
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Selegiline(Eldepryl)
mild sx relief of PD may delay the need for Levodopa by 9mo-1yr use with Levo in advanced dz |
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Nonergotamine Dopamine Agonist
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Pramipexole (mirapex)
Ropinirole (requip) bind D3>D2 and 4 Does not bind D1 and 5 onset is in weeks used in early PD used in late PD with Levodopa to manage motor fluctuations |
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Nonergotamine Dopamine Agonist SE
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generalized edema
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Amantadine (symmetrel)
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antiviral agent
may inc dopa release block dopa reuptake stimulate dopa receptors |
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Amantadine (symmetrel) uses
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bradykinesia
rigidity tremor short term monotherapy early in dz |
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Amantadine (symmetrel) SE
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livedo reticularis
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Ergotamine Dopamine Agonist
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Bromocriptine (Parlodel)
Perglide (Permax) used in early PD to avoid high doses of Levadopa used in advanced PD with Levodopa to managemotor fluctuation WEEKS for onset |
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Ergotamine Dopamine Agonist SE
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dyskinesia
retroperitoneal fibrosis cardiac fibrosisi valvulopathy |
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Injectable Dopamine agonist
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Apomorphine (Apokyn)
for acute intermittent tx of mypomobility "off" episodes ass with advanced parkinsons |
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Injectable Dopamine Agonist SE
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N/V
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Catechol-O-methyltransferase inhibitors (COMT inh)
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Tolcapone (Tasmar)
Entacapone (Comtar) adjuvant therapy to leva/carb significantly increased "on" time and dec "off" time when used with levopdopa Carb/.Lev/Entacapone (Stlevo)- indicated for wearing off |
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COMT inh SE
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urinary discoloration
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Anticholinergics
|
Benztropine (Congentin)
Trihexyphenidyl(Artane) Diphenhydramine (Benadryl) used to control tremor caused y excessive unopposed Ach in neostriatum less effective for bradykinesia and rigidity than other agents |
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Anticholinergics SE:
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Anticholinergic
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Dopamine Agonists
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initial therapy for milder dz with no dementia
cautious induction period required warn pts of risk of sudden sleep attacks switch to levodopa as diseas progresses reintroduce when response to levodopa b/c variable |
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Dopamine Agonists
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Must be slowly titrated
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Dopamine Agonists SE
|
orthostasis
dizziness somnolence hallucinations dyskinesias h/a confusion |
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COMT inhibitors beware of...
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Liver toxicity
esp with tolcapone |
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Specific Drugs indicated for AD Pharmacotherapy
|
Tacrine HCl (Cognex)
Donepezil HCl (Aricept) Rivastigmine tartrate (Exelon) Glantamine NBr (Reminyl) Memantine HCl (Namenda ) |
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Antipsychotics to use cautiously in older pts
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Clozapine
Haldol Olanzapine Risperidone |
