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179 Cards in this Set

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